Daily Anesthesiology Research Analysis
Three impactful anesthesiology studies stood out today: a multicenter RCT (FiiRST-2) found factor concentrates were not superior to plasma in initial trauma resuscitation; a large prospective airway study identified two novel mandibular measures that outperform common bedside tests for predicting difficult laryngoscopy; and a randomized trial showed liposomal bupivacaine intercostal nerve block provides sustained analgesia and opioid-sparing after thoracoscopic surgery.
Summary
Three impactful anesthesiology studies stood out today: a multicenter RCT (FiiRST-2) found factor concentrates were not superior to plasma in initial trauma resuscitation; a large prospective airway study identified two novel mandibular measures that outperform common bedside tests for predicting difficult laryngoscopy; and a randomized trial showed liposomal bupivacaine intercostal nerve block provides sustained analgesia and opioid-sparing after thoracoscopic surgery.
Research Themes
- Trauma resuscitation and hemostatic strategies
- Airway assessment and prediction of difficult laryngoscopy
- Opioid-sparing analgesia and regional anesthesia innovation
Selected Articles
1. Factors in the Initial Resuscitation of Patients With Severe Trauma: The FiiRST-2 Randomized Clinical Trial.
In this multicenter RCT of trauma patients requiring massive hemorrhage protocol, initial resuscitation with fibrinogen concentrate plus PCC did not reduce 24-hour allogeneic transfusion compared with frozen plasma, nor did it improve mortality or thromboembolic outcomes. The trial was stopped for futility after interim analysis.
Impact: This rigorous randomized trial addresses a high-stakes question in trauma anesthesia about replacing plasma with concentrates during initial resuscitation and provides practice-informing negative evidence.
Clinical Implications: For early trauma resuscitation, factor concentrates (FC+PCC) should not be assumed superior to plasma; centers can continue FP-based MTPs without expecting reductions in transfusion needs or mortality from concentrates alone. Resource allocation and protocol updates should consider equivalent efficacy and safety.
Key Findings
- 24-hour allogeneic blood product use: 20.8 units (FC+PCC) vs 23.8 units (FP); no superiority (P=0.20).
- No significant differences in thromboembolic events, 24-hour mortality, or 28-day mortality.
- Trial stopped early for futility due to low conditional power (<25%).
Methodological Strengths
- Multicenter, randomized, parallel-group design with mITT primary analysis
- Standardized initial MHP packs and prespecified outcomes
Limitations
- Early termination reduced sample size and power to detect modest differences
- Crossover or post-pack plasma use at clinician discretion after pack 2 may dilute effects
Future Directions: Head-to-head pragmatic trials powered for mortality and functional outcomes; evaluation of viscoelastic-guided strategies integrating concentrates and plasma; cost-effectiveness and logistics analyses across trauma systems.
2. Could mandibular profile angle or inter-pterygoid distance provide a novel method for predicting difficult laryngoscopy?
In a prospective cohort of 1,001 surgical patients, two novel measures—mandibular profile angle and inter-pterygoid distance—showed high diagnostic performance (AUC ~0.9) and markedly higher sensitivity than Mallampati to predict difficult laryngoscopy. Thresholds of 107.75° and 13.05 cm, respectively, yielded NPVs of 96%.
Impact: Provides practical, quantifiable, and potentially generalizable predictors that outperform common bedside tests and could standardize preoperative airway risk stratification.
Clinical Implications: Incorporating mandibular profile angle and inter-pterygoid distance into preoperative airway assessment may reduce unanticipated difficult laryngoscopy by improving screening sensitivity and NPV. These measures can inform preparation for advanced airway devices and expert assistance.
Key Findings
- Mandibular profile angle: sensitivity 83%, specificity 86%, NPV 96%, AUC 0.89; optimal cutoff 107.75°.
- Inter-pterygoid distance: sensitivity 82%, specificity 88%, NPV 96%, AUC 0.90; optimal cutoff 13.05 cm.
- Modified Mallampati Test sensitivity was only 46% (specificity 91%), underperforming new measures.
Methodological Strengths
- Large prospective sample (n=1001) with prespecified definitions of difficult laryngoscopy
- Direct comparison with standard bedside predictors and reporting of AUC, sensitivity, specificity, PPV/NPV
Limitations
- Single-country, likely single- or limited-center design may limit external validity
- Need for training/standardization to measure novel angles/distances reliably
Future Directions: External validation across diverse populations and settings; integration into multivariable airway prediction models; development of bedside tools or automated imaging to standardize measurements.
3. Liposomal bupivacaine intercostal nerve block for pain control in thoracoscopic surgery: a randomized controlled trial.
In 100 thoracoscopic patients, liposomal bupivacaine intercostal blocks reduced pain scores at rest and with movement across 6–72 hours postoperatively and lowered total opioid consumption versus conventional bupivacaine, without apparent safety signals.
Impact: Addresses a persistent pain-management gap after thoracoscopy with a long-acting formulation showing sustained analgesia and opioid-sparing, directly relevant to enhanced recovery protocols.
Clinical Implications: Liposomal bupivacaine intercostal block can be considered as part of multimodal, opioid-sparing analgesia after thoracoscopic surgery to improve 72-hour pain control and reduce rescue opioids. Cost, availability, and institutional safety protocols should be considered.
Key Findings
- LB group had significantly lower VAS scores at rest and with movement at 6, 8, 12, 24, 48, and 72 hours postoperatively.
- Total postoperative opioid (morphine) consumption and PCA demand frequency were reduced with LB.
- No increase in PONV, pruritus, pulmonary, or cardiovascular complications was reported.
Methodological Strengths
- Prospective randomized, single-blind design with standardized ultrasound-guided technique
- Multiple clinically relevant time-point assessments up to 72 hours
Limitations
- Single-blind and single-study setting; generalizability and cost-effectiveness not assessed
- Details of dosing/concentration and exact effect sizes at each time point not fully detailed in abstract
Future Directions: Head-to-head comparisons with continuous regional techniques; cost-effectiveness analyses; evaluation in high-risk subgroups and combination with other blocks in ERAS pathways.