Daily Anesthesiology Research Analysis
Two large multicenter RCTs in JAMA show that individualized or risk-stratified higher intraoperative MAP targets do not improve early complications or 6-month disability versus standard care (MAP ≥65 mm Hg). A comprehensive BJA network meta-analysis of 105 trials (8008 children) synthesizes how NMBA agent, dose, timing, age, and induction drugs shape pediatric intubation conditions and hemodynamics, offering practice-relevant, dose-aware insights.
Summary
Two large multicenter RCTs in JAMA show that individualized or risk-stratified higher intraoperative MAP targets do not improve early complications or 6-month disability versus standard care (MAP ≥65 mm Hg). A comprehensive BJA network meta-analysis of 105 trials (8008 children) synthesizes how NMBA agent, dose, timing, age, and induction drugs shape pediatric intubation conditions and hemodynamics, offering practice-relevant, dose-aware insights.
Research Themes
- Perioperative blood pressure management
- Pediatric airway pharmacology and NMBA optimization
- Evidence-based anesthesia and negative trials informing practice
Selected Articles
1. Individualized Perioperative Blood Pressure Management in Patients Undergoing Major Abdominal Surgery: The IMPROVE-multi Randomized Clinical Trial.
In 1142 high-risk patients undergoing major abdominal surgery at 15 German centers, individualized MAP targets based on preoperative nighttime MAP did not reduce a 7-day composite of AKI, myocardial injury, nonfatal cardiac arrest, or death versus routine care (RR 1.10; 95% CI 0.93-1.30; P=.31). None of 22 secondary outcomes differed, including infections and a 90-day major adverse event composite.
Impact: A large, multicenter RCT directly tests personalized MAP targeting using ambulatory data and finds no clinical benefit, challenging the adoption of individualized perioperative BP strategies.
Clinical Implications: Maintain standard MAP targets of ≥65 mm Hg during major abdominal surgery; do not escalate complexity by aligning targets to nighttime MAP, as this did not improve early organ injury or mortality.
Key Findings
- Composite primary outcome occurred in 33.5% with individualized MAP vs 30.5% with routine care (RR 1.10; 95% CI 0.93-1.30; P=.31).
- No significant differences across 22 secondary outcomes, including 7-day infections (15.9% vs 17.1%; P=.63) and 90-day KRT/MI/cardiac arrest/death composite (5.7% vs 3.5%; P=.12).
- Intervention set intraoperative MAP targets using preoperative mean nighttime MAP from ambulatory monitoring; control targeted MAP ≥65 mm Hg.
Methodological Strengths
- Multicenter randomized single-blind design with robust sample size across 15 university hospitals
- Prospectively registered (NCT05416944) with standardized, clinically relevant outcomes
Limitations
- Single-blind design may allow performance bias at the provider level
- Generalizability limited to German university hospitals and major abdominal surgery; short primary follow-up (7 days)
Future Directions: Test perfusion-guided strategies (e.g., autoregulation indices, organ-specific perfusion monitoring), evaluate microcirculatory endpoints, and assess different populations and longer-term outcomes.
2. Proactive vs Reactive Treatment of Hypotension During Surgery: The PRETREAT Randomized Clinical Trial.
Among 3247 of 5000 planned noncardiac surgical patients, risk-stratified higher MAP targets (≥70/80/90 mm Hg) did not improve 6-month WHODAS disability versus standard management (mean difference -0.5; 95% CrI -1.9 to 0.9). No secondary outcome differences were observed; the trial stopped early for futility.
Impact: A large pragmatic RCT using a patient-centered disability outcome shows no benefit of higher MAP targets tailored by hypotension risk, narrowing the role for aggressive BP targets in routine anesthesia.
Clinical Implications: Avoid routine escalation of intraoperative MAP targets to ≥80–90 mm Hg based solely on hypotension risk stratification; prioritize prevention of profound hypotension and overall hemodynamic stability under standard practice.
Key Findings
- Risk-stratified MAP goals (≥70/80/90 mm Hg) did not improve 6-month WHODAS scores vs standard care (mean difference -0.5; 95% credible interval -1.9 to 0.9).
- No differences across 23 secondary outcomes; study stopped early for futility after enrolling 3247/5000 patients.
- Population included low (21%), intermediate (56%), and high (23%) hypotension risk categories with predefined MAP targets.
Methodological Strengths
- Randomized pragmatic design with patient-centered primary outcome (WHODAS 2.0) and predefined futility stopping criteria
- Risk-stratified intervention reflecting real-world clinical decision-making
Limitations
- Early trial termination may reduce power to detect smaller effects
- Conducted at two tertiary hospitals; unblinded management could introduce performance variability
Future Directions: Investigate organ-specific perfusion targets and multimodal hemodynamic strategies; assess subgroups (e.g., severe vascular disease) and alternative patient-centered outcomes beyond disability.
3. Effect of neuromuscular blocking agents on tracheal intubation quality in paediatric patients: a systematic review using network meta-analysis and meta-regression.
Across 105 trials including 8008 children, a Bayesian network meta-analysis compared multiple NMBAs and NMBA-free conditions under direct laryngoscopy, evaluating excellent/acceptable intubation conditions and MAP/HR responses. Dose- and agent-related differences, as well as effects of timing, age, and induction drugs, influenced safety and efficacy, with low-to-moderate confidence in recommendations.
Impact: This is a large, methodologically rigorous synthesis clarifying how NMBA type and dose shape pediatric intubation conditions and hemodynamics, providing dose-aware guidance where head-to-head RCTs are sparse.
Clinical Implications: Choose NMBA agent and dose tailored to optimize intubation conditions while monitoring hemodynamics; consider timing, age, and induction drugs. Apply findings with caution due to low-to-moderate confidence and heterogeneity.
Key Findings
- Synthesized 105 trials (8008 participants) comparing various NMBA agents/doses and NMBA-free conditions under direct laryngoscopy.
- Evaluated odds of excellent and acceptable intubation conditions and mean differences in MAP/HR across regimens using Bayesian network meta-analysis and meta-regression.
- Identified that NMBA type, dose, intubation timing, age, and induction drugs contribute to variability in safety and efficacy; recommendations carry low-to-moderate confidence.
Methodological Strengths
- Registered protocol (PROSPERO CRD42018097146) with Bayesian network and pairwise meta-analyses
- Large evidence base with meta-regression to explore heterogeneity and covariate effects
Limitations
- Heterogeneity across trials in dosing, timing, and co-administered agents; some older studies
- Overall confidence graded low-to-moderate, limiting strength of practice recommendations
Future Directions: Design head-to-head pediatric RCTs comparing prioritized NMBA regimens at optimized doses, with standardized timing and induction protocols and patient-centered outcomes.