Daily Anesthesiology Research Analysis
Three anesthesia-relevant studies stand out today: a high-certainty meta-analysis finds videolaryngoscopy does not improve first-pass success over direct laryngoscopy in most pediatric airways; a secondary analysis of a multicentre RCT shows prophylactic noninvasive ventilation reduces post-extubation treatment failure in obese and especially morbidly obese surgical patients; and a perioperative coagulation study reveals divergent behavior of TEG and Quantra fibrinogen metrics after cardiopulmon
Summary
Three anesthesia-relevant studies stand out today: a high-certainty meta-analysis finds videolaryngoscopy does not improve first-pass success over direct laryngoscopy in most pediatric airways; a secondary analysis of a multicentre RCT shows prophylactic noninvasive ventilation reduces post-extubation treatment failure in obese and especially morbidly obese surgical patients; and a perioperative coagulation study reveals divergent behavior of TEG and Quantra fibrinogen metrics after cardiopulmonary bypass, indicating qualitative changes not captured by concentration alone.
Research Themes
- Pediatric airway management and device selection
- Post-extubation respiratory support in obesity
- Perioperative coagulation assessment after cardiopulmonary bypass
Selected Articles
1. Videolaryngoscopy versus direct laryngoscopy for paediatric tracheal intubation: a systematic review with meta-analysis and trial sequential analysis.
Across 53 RCTs (n=4,887), videolaryngoscopy did not improve first-pass success over direct laryngoscopy in mostly normal paediatric airways, despite better glottic visualisation and a modestly longer intubation time. In infants under 1 year, VL reduced oesophageal intubation, though trial sequential analysis suggests evidence remains underpowered for definitive conclusions.
Impact: Provides high-certainty, up-to-date synthesis clarifying when VL confers advantages in paediatric intubation, informing device selection and training priorities.
Clinical Implications: For children with mostly normal airways, routine VL use to increase first-pass success is not supported; DL remains appropriate while VL may be preferred to improve glottic view and reduce oesophageal intubation in infants. Training should ensure proficiency with both devices and context-specific selection.
Key Findings
- No significant difference in first-attempt success between VL and DL (RR 1.03, 95% CI 0.99-1.07; high GRADE certainty).
- VL improved glottic visualisation (POGO +9.8%, 95% CI 3.2-16.4) but slightly increased intubation time (+3 s).
- In children <1 year, VL reduced oesophageal intubation (RR 0.16, 95% CI 0.06-0.40); trial sequential analysis indicates underpowered evidence for definitive effects.
Methodological Strengths
- Included 53 RCTs (n=4,887) with high-certainty GRADE assessment for the primary outcome.
- Prospective protocol registration (PROSPERO) and use of trial sequential analysis to control random errors.
Limitations
- Predominantly normal airways and elective settings limit applicability to difficult airways and emergencies.
- Device heterogeneity and operator experience variability may confound effect estimates.
Future Directions: Head-to-head RCTs in high-risk subgroups (e.g., difficult airways, infants) with standardized operator training and device categories, and patient-centred outcomes (hypoxaemia, complications).
BACKGROUND: Paediatric tracheal intubation presents unique challenges owing to anatomical and physiological characteristics. Multiple intubation attempts increase the risk of severe complications; therefore, achieving high first-pass success is critical. Videolaryngoscopy (VL) represents an alternative to direct laryngoscopy (DL), but its comparative efficacy, safety, and clinical impact in paediatric practice remain under investigation. METHODS: This systematic review and meta-analysis evaluated VL vs DL for paediatric tracheal intubation, focusing on first-attempt success rate, glottic visualisation, intubation time, and critical events. Eight databases were searched. RCTs comparing VL and DL in paediatric patients (<16 yr) were included. RESULTS: Of 22 221 screened articles, 53 RCTs (4887 patients) met inclusion criteria. VL and DL showed comparable first-attempt tracheal intubation success rates, without a statistically significant difference (risk ratio: 1.03, 95% confidence interval [95% CI]: 0.99-1.07, P=0.18). Certainty of evidence was rated as high by the Grading of Recommendations Assessment, Development, and Evaluation criteria. Intubation time was slightly longer with VL (mean difference: +3 s, 95% CI: 0.1-5.4). VL improved glottic visualisation across all paediatric age groups (Percentage of Glottic Opening score, mean difference: 9.8%, 95% CI: 3.2-16.4, P<0.01) and reduced oesophageal intubation in children under 1 yr of age (risk ratio: 0.16, 95% CI: 0.06-0.40, P<0.01). CONCLUSIONS: In paediatric patients with mostly normal airways, no significant differences were observed between VL and DL in achieving first-attempt tracheal intubation success. VL improved glottic visualisation, and, in patients under 1 yr of age, reduced oesophageal intubation with low certainty of evidence. Trial sequential analysis indicates that the available data remain underpowered to confirm a definitive effect. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42024498524).
2. Noninvasive ventilation in postoperative critically ill patients with morbid obesity: secondary analysis of the EXTUBOBESE multicentre randomised clinical trial.
In 585 obese postoperative ICU patients, prophylactic NIV reduced treatment failure compared with oxygen therapy alone (13.4% vs 23.9%; absolute risk difference −10.5%). Reintubation rates did not differ, and benefits were greater in morbid obesity (BMI ≥40), with a significant interaction by obesity level.
Impact: Addresses a common and high-risk postoperative scenario by clarifying that NIV prevents treatment failure after extubation in obese patients, especially those with morbid obesity.
Clinical Implications: Consider routine prophylactic NIV after extubation in obese postoperative ICU patients, particularly with BMI ≥40 kg/m2, while recognizing that reintubation rates may not change. Implementation should include protocols for mask fit, monitoring, and escalation criteria.
Key Findings
- Prophylactic NIV reduced treatment failure vs oxygen therapy (13.4% vs 23.9%; absolute risk difference −10.5, 95% CI −16.8 to −4.3).
- Reintubation rates were similar between groups (8.6% vs 9.9%; P=0.58).
- Effect modification by obesity severity: greater benefit in morbid obesity (BMI ≥40) with significant interaction (P=0.045).
- Findings were consistent whether oxygen therapy used HFNO or standard oxygen.
Methodological Strengths
- Secondary analysis of a multicentre randomized clinical trial with standardized randomization to NIV vs oxygen therapy.
- Predefined subgroup by obesity level with significant interaction testing.
Limitations
- Secondary analysis subject to limitations of post hoc assessments and potential protocol deviations.
- Reintubation not reduced; outcome definitions and clinician-driven decisions may vary across centres.
Future Directions: Prospective RCTs stratified by obesity severity with standardized NIV protocols to test reintubation, hypoxaemia, and patient-centred outcomes; cost-effectiveness and implementation studies.
BACKGROUND: The optimal method to prevent treatment failure after tracheal extubation in postoperative critically ill patients with obesity and morbid obesity remains unknown. METHODS: We conducted a secondary analysis of the EXTUBOBESE multicentre RCT comparing prophylactic noninvasive ventilation (NIV) and oxygen therapy (high-flow nasal oxygen [HFNO] and standard oxygen) in 585 postoperative critically ill patients with obesity (BMI ≥30 kg m RESULTS: Treatment failure occurred in 39/292 patients (13.4%) in the NIV group and in 70/293 patients (23.9%) in the oxygen therapy group (absolute risk difference: -10.5; 95% confidence interval: -16.8 to -4.3). Similar results were found when analysing separately HFNO from standard oxygen in the oxygen therapy group. Reintubation rate was 8.6% (25 patients) in the NIV group and 9.9% (29 patients) in the oxygen therapy group (P=0.58). Interaction test was significant for level of obesity (P=0.045). Time without reintubation according to level of obesity significantly differed between NIV group and oxygen therapy group (P=0.02) in patients with BMI ≥40 kg m CONCLUSIONS: Among postoperative critically ill adults with obesity undergoing tracheal extubation, our results suggest that use of noninvasive ventilation is effective to reduce treatment failure in comparison with oxygen therapy alone. These effects were more pronounced in patients with morbid obesity. CLINICAL TRIAL REGISTRATION: NCT04014920.
3. Changes in the Relationship Between Plasma Fibrinogen Concentration and Functional Clot Strength After Cardiopulmonary Bypass: A Retrospective Observational Study.
After CPB, the relationship between Clauss fibrinogen and functional clot strength diverged by VHA platform: TEG CFF suggested enhanced clot strength per unit fibrinogen immediately post-protamine, whereas Quantra FCS indicated persistently reduced fibrinogen contribution. Conventional labs showed consumption coagulopathy and thrombin generation, underscoring qualitative fibrinogen changes.
Impact: Challenges the assumption that plasma fibrinogen concentration reliably reflects clot function after CPB and highlights device-specific VHA interpretations, directly informing transfusion algorithms.
Clinical Implications: Avoid relying on Clauss fibrinogen alone post-CPB; integrate VHA results with awareness of platform-specific behavior (TEG vs Quantra) when guiding cryoprecipitate/fibrinogen concentrate administration.
Key Findings
- TEG CFF vs Clauss fibrinogen: regression slope increased from 6.12 (T1) to 8.69 (T2) with intercept decreasing from 0.29 to −8.39, indicating greater clot strength per unit fibrinogen immediately post-protamine.
- Quantra FCS vs Clauss fibrinogen: slope decreased from 1.66 (T1) to 0.61 (T2) and 0.72 (T3) with intercept rising from −3.55 to −0.32, suggesting persistently reduced fibrinogen contribution after CPB.
- Conventional coagulation tests showed prolonged PT/aPTT, lower hemoglobin/platelets, and elevated TAT, FDP, and D-dimer, consistent with factor consumption and thrombin generation.
- Findings indicate qualitative alterations in fibrinogen post-CPB; concentration alone may not reflect true coagulative function.
Methodological Strengths
- Relatively large cohort (n=208) with serial measurements at predefined perioperative time points.
- Comparative assessment across two VHA platforms (TEG CFF and Quantra FCS).
Limitations
- Single-centre retrospective design with potential confounding.
- Unequal sample sizes for VHA modalities (CFF n=170 vs FCS n=79) and lack of clinical outcome correlation.
Future Directions: Prospective multicentre studies linking VHA metrics to bleeding, transfusion, and thrombotic outcomes, with head-to-head standardized comparisons of platforms and reagent effects.
OBJECTIVE: To evaluate whether the relationship between plasma fibrinogen concentration (Clauss method) and functional fibrinogen activity as measured by viscoelastic hemostatic assays (VHAs)- thromboelastography-derived citrated functional fibrinogen (CFF) and Quantra-derived fibrinogen contribution to clot stiffness (FCS)-changes before and after cardiopulmonary bypass (CPB). DESIGN: A single-center retrospective observational study. SETTING: Cardiovascular surgery center in Japan. PARTICIPANTS: 208 adult patients undergoing cardiovascular surgery with CPB. INTERVENTIONS: No intervention. MEASUREMENTS AND MAIN RESULTS: Fibrinogen function was assessed at 3 time points: before CPB (T1), immediately after protamine administration (T2), and 1 hour later (T3). CFF (n = 170) and FCS (n = 79) values, along with plasma fibrinogen concentrations, were collected. For CFF, the regression slope against Clauss fibrinogen increased from 6.12 at T1 to 8.69 at T2 (p < 0.05), then returned to 6.58 at T3. The intercept decreased significantly at T2 (from 0.29 to -8.39), indicating enhanced clot strength per unit of fibrinogen. For FCS, the slope decreased from 1.66 at T1 to 0.61 at T2 and 0.72 at T3, and the intercept increased from -3.55 to -0.32, suggesting persistently reduced fibrinogen contribution post-CPB. Conventional tests showed prolonged prothrombin time/activated partial thromboplastin time, decreased hemoglobin and platelet counts, and elevated thrombin antithrombin complex, fibrin/fibrinogen degradation products, and D-dimer levels, indicating coagulation factor consumption and thrombin generation. CONCLUSIONS: The association between fibrinogen concentration and functional clot strength changes significantly after CPB, with contrasting trends in TEG and Quantra. These findings highlight qualitative fibrinogen alterations post-CPB, suggesting that concentration alone might not reflect true coagulative function.