Daily Anesthesiology Research Analysis

IMPORTANCE: Pediatric patients are at an increased risk of postprocedural radial artery occlusion (RAO) owing to their small vessels and high tendency for vasospasm after catheterization. Although subcutaneous nitroglycerin increases the success rate of radial artery catheterization by vasodilation and preventing vasospasm, its effect on RAO prevention after catheter removal remains unknown. OBJECTIVE: To evaluate the efficacy and safety of subcutaneous nitroglycerin for RAO prevention. DESIGN, SETTING, AND PARTICIPANTS: This double-blind randomized clinical trial was conducted at a single tertiary center and included pediatric patients younger than 3 years who required radial artery catheterization during general anesthesia. Study data were analyzed from April to July 2025. INTERVENTIONS: Patients were randomized to receive either subcutaneous nitroglycerin (5 μg/kg/0.5 mL) or normal saline (0.5 mL) above the chosen radial artery before radial arterial catheterization and catheter removal under ultrasound guidance. MAIN OUTCOMES AND MEASURES: The primary outcome was the RAO incidence after catheter removal, assessed using the reverse Barbeau test with pulse oximetry on the ipsilateral index finger. RESULTS: A total of 200 pediatric patients were initially enrolled, but 68 were excluded for protocol violations. In the per-protocol analysis with 132 participants (median [IQR] age, 5.5 [2.0-16.6] months; 73 female [55.3%]), RAO incidence was lower in the nitroglycerin group than in the control group (25.4% [17 of 67] vs 73.8% [48 of 65]; P < .001; odds ratio [OR], 0.12; 95% CI, 0.06-0.26; absolute risk reduction, 48.5%; 95% CI, 33.6%-63.4%). After catheter removal, the nitroglycerin group showed higher peak blood flow velocity (mean [SD], 13.0 [11.0] cm/s vs 7.4 [9.2] cm/s; 95% CI for mean difference, 2.1-9.1 cm/s; P = .002) and perfusion index (mean [SD], 1.37 [1.09] vs 0.65 [0.49]; 95% CI for mean difference, 0.43-1.01; P < .001) of the radial artery than did the control group. There was no significant intergroup difference in RAO duration. There was no hypotension or localized adverse effects. CONCLUSIONS AND RELEVANCE: Subcutaneous nitroglycerin injection before radial artery catheterization and catheter removal significantly reduced the incidence of RAO after catheter removal and may promote safe recovery in pediatric patients younger than 3 years. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05443061.

BACKGROUND: Neonatal outcomes with regional anesthesia (spinal, epidural, or combined spinal-epidural) versus general anesthesia for cesarean delivery remain poorly characterized. The authors performed a meta-analysis of randomized trials to compare neonatal outcomes associated with each technique. They hypothesized that regional anesthesia would be associated with higher Apgar scores and less need for respiratory support and neonatal intensive care after delivery. METHODS: The authors searched randomized controlled trials comparing regional versus general anesthesia for patients undergoing cesarean delivery between January 1994 and November 2023. They abstracted information on study characteristics, Apgar score at 1 and 5 min, need for respiratory support after delivery, and need for neonatal intensive care. They analyzed summary data using random effects models and assessed risk of bias using the Cochrane Risk of Bias 2 scale. RESULTS: A total of 36 studies involving 3,456 neonates were included. Of the neonates, 42.7% (n = 1,476) were born to parturients who underwent general anesthesia, and 57.3% (n = 1,980) were born to parturients who underwent regional anesthesia. Apgar scores at 1 and 5 min were slightly higher after regional versus general anesthesia (mean difference at 1 min, 0.58 points; 95% CI, 0.36 to 0.79; P < 0.001; mean difference at 5 min, 0.09 points; 95% CI, 0.05 to 0.13; P < 0.001). Respiratory support was less often required with regional anesthesia (risk ratio, 0.62; 95% CI, 0.40 to 0.94; P = 0.03). Need for neonatal intensive care did not differ across techniques (risk ratio, 0.75; 95% CI, 0.46 to 1.21; P = 0.24). All studies had high or unclear risk of bias. CONCLUSIONS: Regional anesthesia for cesarean delivery is associated with slightly higher Apgar scores and less frequent need for neonatal respiratory support than general anesthesia. Additional studies are required to determine associations of anesthesia technique with need for intensive care and longer-term outcomes.

BACKGROUND: Approximately half of the patients with acute respiratory distress syndrome (ARDS) receiving extracorporeal membrane oxygenation (ECMO) remain ECMO-dependent beyond 14 days after ECMO initiation. The identification of factors associated with mortality during an ECMO run may update prognostic assessment and focus clinical interventions. METHODS: In this observational study, data from 1137 patients with COVID-19 ARDS receiving ECMO support in 29 German centers between January 1st 2020 and July 31st 2021 were analyzed. Multivariable stepwise logistic regression analyses were performed to build survival prediction models with day-by-day data during the first 14 days of an ECMO run. The primary endpoint was all-cause mortality in the intensive care unit. RESULTS: Mortality in this cohort was high (75%). Patients who remained ECMO-dependent on day 14 of their ECMO run showed comparable mortality to all patients receiving ECMO support on day 1. Yet, factors associated with mortality changed during the first 14 days of ECMO support. On day 1 of ECMO support, only patient age and lactate remained in the final mortality prediction model. On day 14 of an ECMO run, tidal volume was independently associated with mortality (adjusted Odds Ratio 0.693 (95%CI 0.564-0.851), p < 0.001 for 1 mL/kg increase in tidal volume per predicted body weight). The adjusted mortality for patients with a tidal volume below 2 mL/kg on day 14 of their ECMO run was above 80% (lower limit of the 95%CI interval). Higher tidal volume was mainly based on higher respiratory system compliance. Yet, the benefit of higher compliance was not observed in some patients who were still ventilated with very low driving pressures despite remaining ECMO-dependent on day 14 of ECMO support. CONCLUSIONS: Mortality predictors change during the course of an ECMO run. In a cohort with high mortality, on day 14 of ECMO support for ARDS, tidal volume may be an independent predictor of mortality. Further analyses on ventilation strategies in patients who remain ECMO-dependent are needed. TRIAL REGISTRATION NUMBER: DRKS00022964, retrospectively registered.