Daily Anesthesiology Research Analysis
Three studies stand out for immediate perioperative relevance: a comprehensive meta-analysis shows upper airway point-of-care ultrasound can accurately predict difficult laryngoscopy/intubation; a pragmatic multicenter RCT finds no benefit of supplemental parenteral nutrition within ERAS after pancreatoduodenectomy; and a pediatric RCT demonstrates THRIVE substantially reduces hypoxemia during sedated gastroscopy.
Summary
Three studies stand out for immediate perioperative relevance: a comprehensive meta-analysis shows upper airway point-of-care ultrasound can accurately predict difficult laryngoscopy/intubation; a pragmatic multicenter RCT finds no benefit of supplemental parenteral nutrition within ERAS after pancreatoduodenectomy; and a pediatric RCT demonstrates THRIVE substantially reduces hypoxemia during sedated gastroscopy.
Research Themes
- Airway assessment with point-of-care ultrasound
- Perioperative nutrition within ERAS pathways
- Pediatric peri-procedural oxygenation strategies (THRIVE)
Selected Articles
1. Point-of-care ultrasound of the upper airway in difficult airway management: a systematic review and meta-analysis.
Across 60 studies (10,580 patients), upper airway point-of-care ultrasound parameters showed strong diagnostic accuracy for predicting difficult laryngoscopy (skin-to-vocal cords distance: sensitivity 0.84, specificity 0.81; AUROC 0.87) and difficult intubation (skin-to-epiglottis distance: sensitivity 0.80, specificity 0.86). Ultrasound guidance also improved first-pass success for percutaneous tracheostomy and cricothyroid membrane identification.
Impact: Provides high-certainty evidence to integrate airway ultrasound into preoperative assessment and procedural planning, potentially reducing failed attempts and complications.
Clinical Implications: Incorporate standardized airway ultrasound measurements (e.g., skin-to-vocal cord and skin-to-epiglottis distances) into difficult airway assessment and use ultrasound to guide cricothyroid membrane localization and percutaneous tracheostomy.
Key Findings
- Skin-to-vocal cords distance predicted difficult laryngoscopy with sensitivity 0.84, specificity 0.81, AUROC 0.87.
- Skin-to-epiglottis distance predicted difficult intubation with sensitivity 0.80 and specificity 0.86; skin-to-hyoid had AUROC 0.86.
- Ultrasound guidance increased first-pass success in percutaneous tracheostomy (OR ~3.9) and improved cricothyroid membrane identification (OR ~3.61) versus palpation.
Methodological Strengths
- Large evidence base: 60 studies and 10,580 patients
- Quantitative synthesis with sensitivity, specificity, and AUROC estimates; certainty of evidence assessed
Limitations
- Heterogeneity across studies and parameters; not all analyses were high-certainty
- Diagnostic thresholds and scanning protocols may vary, limiting standardization
Future Directions: Prospective multicenter studies integrating airway ultrasound with clinical predictors to derive standardized cutoffs and algorithms, especially in high-risk populations.
2. Supplemental parenteral nutrition within an enhanced recovery program for open pancreatoduodenectomy for cancer: a pragmatic, multicenter, randomized controlled trial.
In a pragmatic multicenter RCT (n=254) under ERAS with early oral feeding, supplemental parenteral nutrition after open pancreatoduodenectomy did not reduce morbidity burden (median CCI 20.9 in both arms) or complication rates up to 90 days, including in high nutritional risk patients.
Impact: High-quality negative evidence that can de-implement routine SPN in ERAS for PD, simplifying care and reducing costs and line-related risks.
Clinical Implications: Do not routinely administer SPN after PD within ERAS pathways emphasizing early oral feeding; reserve parenteral nutrition for severely malnourished or clinically unstable patients not represented in this trial.
Key Findings
- Median Comprehensive Complication Index was identical (20.9) in SPN and no-SPN arms; median difference 0 (95% CI -1.07 to 1.7).
- 90-day morbidity was similar (63.2% SPN vs 67.4% no-SPN; risk difference -4.2, 95% CI -16.7 to 8.2).
- No protective effect of SPN in high nutritional risk subgroup (OR 1.16, 95% CI 0.71-1.91).
Methodological Strengths
- Pragmatic multicenter randomized controlled design with ITT analysis
- Pre-registered trial with clearly defined outcomes and ERAS-standardized care
Limitations
- Excluded severely malnourished patients and those with critical comorbidities, limiting generalizability
- Conducted within a single country and specific ERAS protocol
Future Directions: Evaluate targeted nutrition triggers and individualized criteria for parenteral nutrition in non-ERAS contexts or in severely malnourished/high-risk cohorts.
3. Effect of transnasal humidified rapid-insufflation ventilatory exchange on the incidence of hypoxemia in sedated gastroscopy in children: a randomised controlled trial.
In 120 children undergoing sedated gastroscopy, THRIVE reduced hypoxemia incidence (8.3% vs 28.3%), shortened hypoxemia duration, lowered respiratory intervention needs and complications, and improved endoscopist satisfaction versus nasal cannula oxygen.
Impact: Addresses a common safety issue in pediatric procedural sedation with an easily implementable, scalable oxygenation strategy.
Clinical Implications: Consider THRIVE for children (ASA I–II) undergoing sedated gastroscopy to reduce hypoxemia and rescue interventions; ensure protocols and monitoring are in place.
Key Findings
- Hypoxemia incidence: 8.3% (THRIVE) vs 28.3% (nasal cannula), P<0.01.
- Shorter hypoxemia duration with THRIVE (9.0 ± 1.73 s vs 13.18 ± 3.49 s; 95% CI -6.63 to -1.72; P<0.01).
- Lower respiratory intervention rate (11% vs 30%; P<0.05) and fewer adverse respiratory events (13.3% vs 30%; P<0.05); higher operator satisfaction (88.3% vs 68.3%; P<0.05).
Methodological Strengths
- Prospective randomized controlled design with clearly defined primary and secondary outcomes
- Direct comparison to standard nasal cannula oxygen in a homogeneous pediatric cohort
Limitations
- Single-center trial; generalizability to broader pediatric populations and other procedures is uncertain
- ASA I–II and age 6–12 only; not powered for rare adverse events
Future Directions: Multicenter RCTs across broader pediatric age ranges and procedures, evaluation of optimal flow settings and cost-effectiveness.