Daily Anesthesiology Research Analysis

IMPORTANCE: Patients with bleeding and coagulopathic trauma often require more transfusions and have higher mortality rates, motivating research on improving hemostatic strategies. OBJECTIVE: To evaluate the replacement of clotting factors with frozen plasma (FP) or factor concentrates (fibrinogen concentrate [FC] and prothrombin complex concentrate [PCC]) in the initial resuscitation of patients with trauma. DESIGN, SETTING, AND PARTICIPANTS: This multicenter, parallel-control, superiority randomized clinical trial was conducted at 6 level I trauma centers in Canada, between April 2021 and February 2023. Eligible patients were those with massive hemorrhage protocol (MHP) activation on admission and aged 16 years or older. Patients were excluded if they received more than 2 red blood cell (RBC) units either before hospital admission or in the hospital prior to randomization or if they had a catastrophic head injury. Follow-up was completed on March 25, 2023. The primary analysis was based on the modified intention-to-treat approach. INTERVENTIONS: The intervention group received FC 4 g and PCC 2000 IU in MHP packs 1 and 2. The control group received 4 FP units. Concurrently, patients received 4 RBC units (both packs) and 1 dose of platelets (pack 2). After pack 2, FP was administered at clinician discretion. MAIN OUTCOMES AND MEASURES: Primary outcome was the number of allogeneic blood product (RBC, FP, and platelet) units administered within 24 hours. Secondary outcomes included incidence of thromboembolic events, duration of intensive care unit stay, and mortality. RESULTS: Of the 217 patients enrolled, 107 were randomly assigned to the FC-PCC group and 110 to the FP group; 137 patients were included in the primary analysis (66 in the FC-PCC group and 71 in the FP group). Baseline characteristics were similar between groups (median [IQR] age, 38 [29-55] years; 111 males [81.0%]). Among these patients, 95 (69.3%) had blunt mechanisms of injury, and the median (IQR) Injury Severity Score was 29 (19-43). Mean 24-hour transfusions were 20.8 (95% CI, 16.7-25.9) units in the FC-PCC group and 23.8 (95% CI, 19.2-29.4) units in the FP group. The mean ratio was 0.87 (1-sided 97.5% CI, 0.00-1.19; P = .20 for superiority). No significant differences were found in thromboembolic complications or 24-hour and 28-day mortality. The trial was terminated after the interim analysis showed conditional power of less than 25%, requiring an impractically large sample to show superiority. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, clotting factor concentrates were not superior to FP for initial resuscitation of patients with trauma. Efficacy and safety outcomes were similar across the treatment groups. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04534751.

BACKGROUND: Various tests have been developed to predict difficult airway during preoperative examination, but none has presented an adequate degree of accuracy. This study investigates novel mandibular structures and angles for evaluation as potential predictor of difficult laryngoscopy. METHODS: Following Ethics Committee approval, 1001 patients scheduled for elective surgeries under general anesthesia with oral intubation were included in this prospective study. Difficult laryngoscopy was defined as a Cormack-Lehane grade III or IV view. Standard predictive tests - including neck circumference, thyromental distance, sternomental distance, Modified Mallampati Test (MMT), mouth opening, and upper lip bite test - were evaluated alongside two novel parameters: the "mandibular profile angle" and "inter-pterygoid distance." RESULTS: The sensitivity and specificity of the Modified Mallampati Test (MMT) for predicting difficult laryngoscopy were 46% and 91%, respectively, with a positive predictive value (PPV) of 51% and a negative predictive value (NPV) of 89%. In contrast, the "mandibular profile angle" demonstrated a sensitivity of 83%, specificity of 86%, PPV of 55%, and NPV of 96%. The "inter-pterygoid distance" showed similar accuracy, with a sensitivity of 82%, specificity of 88%, PPV of 58%, and NPV of 96%. The area under the curve (AUC) values were 0.89 for the "mandibular profile angle" and 0.90 for the "inter-pterygoid distance." The optimal cut-off for predicting difficult laryngoscopy was 107.75° for the "mandibular profile angle" and 13.05 cm for the "inter-pterygoid distance." CONCLUSIONS: These findings suggest that using mandibular structures in preoperative assessments to anticipate and prepare for difficult laryngoscopy scenarios provides reliable threshold values that may improve patient safety and procedural outcomes. The introduction of novel measurements, specific to mandibular structure assessment, carries the potential to initiate a distinct approach in predicting difficult laryngoscopy. By integrating these measurements with existing bedside tests, a substantial enhancement in the accuracy and robustness of predictive evaluations may be reached.

OBJECTIVE: This study aimed to evaluate and compare the analgesic efficacy of liposomal bupivacaine (LB) versus conventional bupivacaine hydrochloride for intercostal nerve block after thoracoscopic surgery. DESIGN: A prospective, randomized, controlled, single-blind study. SETTING: The study was conducted in the operating room, post-anesthesia care unit (PACU), and general ward. PARTICIPANTS: A total of 100 patients classified as ASA physical status II-III who were scheduled for thoracoscopic surgery were enrolled. INTERVENTIONS: Participants were randomly allocated to receive either LB or conventional bupivacaine hydrochloride via intercostal nerve block, performed under ultrasound guidance. All patients received intravenous patient-controlled analgesia (PCA) without a continuous background infusion. Rescue morphine was administered as needed if the PCA failed to provide adequate pain relief (VAS ≥ 4). MEASUREMENTS: The primary outcome was postoperative pain intensity assessed using the Visual Analog Scale (VAS; 0-10) both at rest and during exercise at 6, 8, 12, 24, 48, and 72 h after surgery. Secondary outcomes included total morphine consumption, PCA demand frequency, patient satisfaction scores, intraoperative remifentanil dose, and length of hospital stay. Safety outcomes included the incidence of postoperative nausea and vomiting (PONV), pruritus, pulmonary complications, and cardiovascular events. RESULTS: Baseline characteristics and surgical procedures were comparable between groups. Compared with conventional bupivacaine, the LB group showed significantly lower VAS scores at rest and during exercise at all six postoperative time points (6-72 h; all CONCLUSION: LB provided sustained and effective postoperative analgesia for 72 h after thoracoscopic surgery, while significantly reducing opioid consumption ( CLINICAL TRIAL REGISTRATION: www.chictr.org.cn, ChiCTR2300076708.