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.
IMPORTANCE: Intraoperative hypotension is associated with organ injury. However, it remains unknown if targeted blood pressure management during surgery can improve clinical outcomes. OBJECTIVE: To evaluate whether individualized vs routine perioperative blood pressure management during major abdominal surgery improves clinical outcomes in patients considered at high risk of postoperative complications. DESIGN, SETTING, AND PARTICIPANTS: This randomized single-blind clinical trial enro
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.
IMPORTANCE: Intraoperative hypotension is associated with adverse postoperative outcomes, but whether a proactive strategy to prevent intraoperative hypotension improves outcomes is uncertain. OBJECTIVE: To determine whether intraoperative blood pressure management stratified by risk of hypotension reduces postoperative functional disability compared with usual care in adults undergoing noncardiac surgery. DESIGN, SETTING, AND PARTICIPANTS: In this randomized clinical trial, adults undergoin
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.
BACKGROUND: This meta-analysis is the first to compare tracheal intubation conditions and haemodynamic responses produced by various types and doses of neuromuscular blocking agents (NMBAs) in paediatric anaesthesia while also exploring factors associated with variability in outcomes. METHODS: Randomised controlled and controlled clinical trials involving healthy paediatric participants (0-12 yr) were included. Trials compared intubation conditions using various NMBA interventions or NMBA-free s