Daily Anesthesiology Research Analysis
Three studies inform perioperative and critical care practice in anesthesiology. A randomized trial after liver transplantation found that higher MAP targets did not reduce AKI and were associated with more graft rejection. Large observational work refined hemodynamic management: a multicenter ECMO cohort linked thrombocytopenia to bleeding and mortality, and a Nature Communications study introduced validated, personalized MAP/HR targets associated with lower ICU mortality.
Summary
Three studies inform perioperative and critical care practice in anesthesiology. A randomized trial after liver transplantation found that higher MAP targets did not reduce AKI and were associated with more graft rejection. Large observational work refined hemodynamic management: a multicenter ECMO cohort linked thrombocytopenia to bleeding and mortality, and a Nature Communications study introduced validated, personalized MAP/HR targets associated with lower ICU mortality.
Research Themes
- Personalized hemodynamic targets in critical care
- Thrombocytopenia and bleeding risk during VV-ECMO
- Post-transplant blood pressure targets and renal outcomes
Selected Articles
1. Higher vs standard mean arterial pressure target in the immediate postoperative period of liver transplantation to prevent acute kidney injury: A randomized clinical trial (LIVER-PAM).
In a single-center randomized trial after liver transplantation, targeting MAP 85–90 mmHg for 24 hours did not reduce 7-day AKI versus 65–70 mmHg, though MAKE28 was lower. Notably, biopsy-proven rejection requiring pulse therapy was more frequent with higher MAP.
Impact: This pragmatic RCT challenges the assumption that higher early MAP universally protects kidneys post-transplant and highlights a potential trade-off with increased rejection.
Clinical Implications: Avoid routine escalation to MAP 85–90 mmHg in the immediate post–liver transplant period solely to prevent AKI. Standard MAP 65–70 mmHg remains appropriate while individualizing care; weigh any potential MAKE28 benefits against a higher rejection risk.
Key Findings
- No difference in 7-day AKI: 69.7% (high MAP) vs 69.4% (standard); RR 1.00 (95% CI 0.82–1.22).
- Lower 28-day major adverse kidney events in the high MAP group (56.1% vs 72.9%; RR 0.77, 95% CI 0.61–0.96).
- Higher rate of graft rejection requiring pulse therapy with higher MAP (12.5% vs 3.5%; RR 3.54, 95% CI 1.02–12.25).
Methodological Strengths
- Randomized clinical trial with prespecified MAP targets and clinically relevant endpoints (AKI, MAKE28, rejection).
- Clear intervention window (first 24 hours) enabling protocolized hemodynamic management.
Limitations
- Single-center, open-label design limits generalizability and may introduce performance bias.
- Primary endpoint incidence was high; the trial may be underpowered to detect modest differences in AKI or to fully assess immunological mechanisms underlying increased rejection.
Future Directions: Multicenter RCTs with stratification by vasopressor type and immunologic monitoring are needed to reconcile MAKE28 benefits with rejection risk and to define patient subgroups that may benefit from higher MAP.
Acute kidney injury (AKI) is a frequent complication after liver transplantation, with an incidence up to 81%, and is associated with impaired long-term renal function, graft survival, and increased mortality. Hypotension is a modifiable risk factor, and while maintaining a mean arterial pressure (MAP) >65 mmHg is standard practice, higher targets may improve outcomes. The LIVER-PAM trial was an open-label, single-center, randomized clinical trial including 174 adult patients treated in an intensive care unit after liver transplantation. Patients were randomized to a higher MAP target (85-90 mmHg) or a standard target (65-70 mmHg) during the first 24 postoperative hours. The primary outcome was AKI incidence within 7 days. Secondary outcomes included major adverse kidney events at 28 days, graft rejection, and 11 additional endpoints. AKI occurred in 69.7% of patients in the higher MAP group and 69.4% in the standard MAP group (relative risk [RR], 1.00; 95% confidence interval (CI), 0.82-1.22; P = .97). Major adverse kidney events at 28 days was lower in the higher MAP group (56.1% vs 72.9%; RR 0.77, 95% CI, 0.61-0.96, P = .02. Graft rejection requiring pulse therapy was more frequent in the higher MAP group (12.5% vs 3.5%; RR, 3.54; 95% CI, 1.02-12.25; P = .03). A higher MAP target did not reduce AKI incidence within 7 days postliver transplantation.
2. The HM-TARGET personalised real-time haemodynamic targets in critical care.
Using time-dependent modeling, HM-TARGET personalizes systolic BP and HR goals that adapt over time and generalize across datasets, with proximity to model-predicted targets associated with lower ICU mortality. This supports moving beyond fixed thresholds toward precision haemodynamic management.
Impact: Introduces a validated, scalable precision-medicine approach to haemodynamics with strong predictive performance and outcome associations across external cohorts.
Clinical Implications: Bedside decision-support could target individualized BP/HR rather than fixed MAP thresholds. Implementation should be accompanied by trials to confirm causality and safety before changing practice.
Key Findings
- Time-dependent Cox model generated personalized, real-time BP/HR targets with c-index up to 0.931.
- External validation across MIMIC-IV and IU Health cohorts demonstrated generalizability.
- Closer adherence to model-predicted targets correlated with lower ICU mortality versus adherence to fixed thresholds; exploratory dose-response and propensity analyses supported robustness.
Methodological Strengths
- Model development with external validation across multiple large ICU datasets.
- Time-adaptive risk modeling integrating static and dynamic variables; supportive causal inference analyses (propensity matching, dose-response).
Limitations
- Observational design precludes causal inference; associations may reflect residual confounding.
- Operational feasibility and clinician uptake were illustrated via case studies but not tested in a randomized implementation trial.
Future Directions: Cluster-randomized or stepped-wedge trials testing HM-TARGET-driven decision support versus usual care, with safety, workload, and outcome endpoints.
Haemodynamic management in critical care typically relies on static, population-based targets that overlook patient-specific physiology and the evolving nature of illness. We develop and validate a framework for real-time, personalised haemodynamic management using a time-dependent Cox model that integrates static and dynamic clinical data to predict survival probabilities and derive optimal heart rate and systolic blood pressure targets over time. Trained on the electronic Intensive Care Unit dataset and externally validated with Medical Information Mart for Intensive Care IV and Indiana University Health cohorts, the model demonstrates high predictive accuracy (c-index up to 0.931) and generalisability across diverse populations. Patients with heart rate and systolic blood pressure values closer to model-predicted targets exhibit significantly lower intensive care unit mortality than those aligned with fixed, population-based thresholds. Exploratory dose-response and propensity score-matched analyses confirm outcome relevance, while case studies illustrate feasibility in critical care settings. This personalised, dynamic approach-termed Haemodynamic Management by Time-Adaptive, Risk-Guided Estimation of Targets (HM-TARGET)-offers a scalable framework for precision haemodynamic management in critically ill patients. Prospective trials are warranted to evaluate clinical impact.
3. Incidence, kinetics, and clinical impact of thrombocytopenia in venovenous ECMO: insights from the multicenter observational PROTECMO study.
In 652 VV-ECMO patients, thrombocytopenia occurred in 80% and was strongly associated with increased bleeding and reduced 6‑month survival, especially at platelet counts below 100×10^9/L. These data refine transfusion and anticoagulation strategies during ECMO.
Impact: Provides large, prospective multicenter evidence quantifying the incidence and prognostic impact of thrombocytopenia during VV-ECMO, informing bleeding risk mitigation.
Clinical Implications: Monitor platelet trajectories closely; consider thresholds around 100×10^9/L when balancing bleeding risk, anticoagulation, and transfusion practices, acknowledging center-level protocols.
Key Findings
- Baseline thrombocytopenia present in 27.9%; thrombocytopenia occurred at least once during ECMO in 80.2% of patients.
- Severity distribution during ECMO: mild 21.3%, moderate 32.2%, severe 26.7%.
- Lower platelet counts, particularly <100×10^9/L, were associated with higher bleeding risk and reduced 6‑month survival.
Methodological Strengths
- Prospective, multicenter design with a large sample (n=652).
- Standardized classification of thrombocytopenia severity and assessment of bleeding and survival outcomes.
Limitations
- Observational design limits causal inference and is susceptible to practice variability across centers.
- Specific anticoagulation regimens, transfusion triggers, and device-related factors may confound associations.
Future Directions: Randomized or protocolized studies testing platelet threshold–based transfusion strategies and anticoagulation adjustments to reduce bleeding without compromising oxygenation and circuit patency.
BACKGROUND: Thrombocytopenia is a recognized risk factor for bleeding during extracorporeal membrane oxygenation (ECMO). This study determines the incidence, risk factors, and clinical relevance of thrombocytopenia and platelet transfusions during venovenous (VV) ECMO. METHODS: The multicenter, prospective observational PROTECMO study included 652 adult patients who received VV ECMO for respiratory failure. Thrombocytopenia was classified as mild (100-149·10 RESULTS: A total of 182 patients (27.9%) had thrombocytopenia at baseline (mild in 14.7%, moderate in 8.7%, and severe in 4.4%). Thrombocytopenia during ECMO, at least once in 80.2% of patients, was mild in 21.3% of cases, moderate in 32.2%, and severe in 26.7%. A 10·10 CONCLUSIONS: Thrombocytopenia is highly prevalent in VV ECMO, and associated with a significant increase in the risk of bleeding, and a reduction in 6-month survival, particularly at platelet counts below 100·10