Daily Anesthesiology Research Analysis

BACKGROUND: Traumatic brain injury (TBI) remains a leading cause of morbidity and mortality worldwide. Secondary brain insults related to oxygenation and ventilation may affect outcomes in this high-risk population. The aim of this study was to perform a comprehensive review examining the relationship between oxygen and carbon dioxide thresholds and mortality to guide clinical care. METHODS: Eleven databases, including: MEDLINE, MEDLINE In-Process, Embase, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, CINAHL, APA PsycINFO, Web of Science, Biosys, Scopus, and the Global Index Medicus, were systematically searched from inception to October 23, 2024. Included studies reported on adults (≥18 years) with moderate to severe TBI (msTBI) (Glasgow Coma Scale <13 or Head Abbreviated Injury Scale ≥3) and exposure to hypoxia, hypocapnia, or hypercapnia, with mortality or vegetative state data reported within 6 months. Vegetative state data was not reported, so all analyses were based on mortality. Pediatric or mild TBI studies, stroke-focused studies, and studies without mortality outcomes were excluded. The data were screened via Covidence software with multiple reviewers. No language or regional restrictions were applied. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Quality was assessed via the Newcastle-Ottawa Scale (NOS) for Cohort Studies, and certainty of evidence was rated using GRADE. Four authors independently extracted data with verification by a second reviewer. The primary outcome was measured using odds ratios (ORs) with 95% confidence intervals (CIs), calculated separately for crude and adjusted effect estimates. RESULTS: Twenty-one cohort studies with 41,980 patients were included. Hypoxia and hypocapnia were significantly associated with increased mortality (aOR, 1.39; 95% CI 1.11-1.75; p =.005; aOR, 1.64; 95% CI 1.25-2.15; p <.001). Hypercapnia was not significantly associated with mortality (aOR, 1.74; 95% CI 0.91-3.32; p =.09). CONCLUSIONS: In adults with msTBI, hypoxia and hypocapnia were independently associated with increased mortality, underscoring the importance of prompt recognition and targeted management of these secondary injuries. The role of hypercapnia remains unclear, warranting further investigation.

OBJECTIVES: Pediatric acute respiratory distress syndrome (PARDS) guidelines recommend limiting airway plateau pressure (Pplat) to 28 cm H 2 O, allowing for higher limits when chest wall compliance (C CW ) is poor since less of the pressure is transmitted to lung (transpulmonary pressure). Transpulmonary pressure depends on Pplat and the ratio of lung elastance to respiratory system elastance (E L /E RS ). E L /E RS measurement requires esophageal manometry, although it is not routinely available. We sought to determine if routinely available clinical data could reliably predict E L /E RS or changes in E L /E RS , to understand when Pplat greater than 28 cm H 2 O could be acceptable. DESIGN: Secondary analysis of randomized controlled trial with esophageal manometry monitoring. SETTING: Quaternary PICU. PATIENTS: Mechanically ventilated children with PARDS. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two hundred seven patients and 750 patient days were included. Using the first day per patient, median E L /E RS was 0.83 (interquartile range, 0.72-0.87), with a weak negative correlation with respiratory system compliance (C RS ) ( r = -0.26; p < 0.001). C RS was strongly correlated with lung compliance (C l ) ( r = 0.94; p < 0.001) and moderately correlated with C CW ( r = 0.53; p < 0.001). Multivariable analysis identified that higher C RS , younger age and peripheral neuromuscular disease were associated with higher C CW , while higher C RS was the only variable independently associated with higher C l (all p < 0.01). When trying to predict high (> 0.9) or low (< 0.7) E L /E RS , C RS was the only variable retaining an independent association: lower C RS (C RS × 10 [mL/cm H 2 O/kg × 1/10]) with high E L /E RS (odds ratio [OR], 0.70; 95% CI, 0.54-0.86; p = 0.002; area under the receiver operating characteristic curve [AUC], 0.73) and higher C RS (C RS × 10 [mL/cm H 2 O/kg × 1/10]) with low E L /E RS (OR, 1.14; 95% CI, 1.02-1.28; p = 0.017; AUC, 0.60). Change in E L /E RS from day to day was not predictable. CONCLUSIONS: In PARDS, C RS is more strongly tied to C l than C CW . While E L /E RS is not easily predictable from clinical variables, when C RS is low, E L /E RS is generally high. Therefore, increasing Pplat above the suggested thresholds when C RS is impaired may be inappropriate without measuring esophageal pressure.

BACKGROUND: Regional anesthetic techniques are applied in cardiac surgery to improve postoperative pain and accelerate recovery. Pecto-intercostal fascial block (PIFB) combined with rectus sheath block (RSB) has been proved to provide ideal analgesia for cardiac surgery, but the effects of combing regional anesthetic techniques on postoperative recovery are uncertain. METHODS: This is a prospective and randomized controlled trial at Fuwai Hospital from 1 June 2024 to 3 July 2024. Eighty patients undergoing elective cardiac surgery via cardiopulmonary bypass were randomized at a 1:1 ratio to be allocated in the intervention group (PIFB combined with RSB) or control group (without regional blocks). The primary outcome was the global score of the 15-item quality of recovery (QoR-15) questionnaire at 24 h after surgery. Secondary outcomes included QoR-15 at 72 h, postoperative pain scores, time to extubation, length of stay, medical expenses in hospital and postoperative morbidities. RESULTS: The QoR-15 global score at 24 h after cardiac surgery was 122.35±6.71 in the intervention group vs 115.30±5.90 in the control group (P<.001). The proportion of patients experiencing better quality of recovery (Qor-15≥118) was higher in the intervention group (77.5% vs 55%, P=.033). Postoperative pain scores were 1.90±0.18 in the intervention group compared to 2.95±0.99 in the control group (P=.027) at 24 h. Time to extubation was earlier in the intervention group (274.40±98.36 vs 741.28±93.82 min, P<.001). There were no statistically differences in Qor-15 at 72 h and other recovery outcomes. CONCLUSION: The administration of PIFB combined with RSB could improve quality of recovery and relieve postoperative pain for patients following cardiac surgery. Key message What is already known on this topic Previous studies have demonstrated that ultrasound-guided nerve blocks effectively reduce postoperative pain in cardiac surgery patients. However, whether these techniques further enhance overall postoperative recovery remained unclear. What this study adds This trial revealed that ultrasound-guided nerve blocks improved postoperative QoR-15 scores, and combined regional techniques further improved recovery without compromising analgesia. How this study might affect research, practice, or policy The findings support applying combined nerve blocks into enhanced recovery protocols for cardiac surgery, offering evidence to optimize postoperative analgesia strategies.