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).
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.
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.