Daily Anesthesiology Research Analysis
A Cochrane meta-analysis across 61 trials confirms that restrictive red blood cell transfusion strategies minimize exposure without increasing 30-day mortality, with nuanced exceptions in gastrointestinal bleeding and neurocritical care. A randomized, sham-controlled trial shows preoperative transcranial direct current stimulation significantly reduces postoperative delirium after major laparoscopic surgery. A phase 2 multicenter RCT suggests Daikenchuto (TU-100) as an ERAS-compatible adjunct th
Summary
A Cochrane meta-analysis across 61 trials confirms that restrictive red blood cell transfusion strategies minimize exposure without increasing 30-day mortality, with nuanced exceptions in gastrointestinal bleeding and neurocritical care. A randomized, sham-controlled trial shows preoperative transcranial direct current stimulation significantly reduces postoperative delirium after major laparoscopic surgery. A phase 2 multicenter RCT suggests Daikenchuto (TU-100) as an ERAS-compatible adjunct that shortens length of stay after bowel resection at a 7.5 g/day dose.
Research Themes
- Perioperative transfusion strategies and patient-centered thresholds
- Nonpharmacological neuromodulation to prevent postoperative delirium
- Traditional medicine adjuncts integrated into ERAS pathways
Selected Articles
1. Transfusion thresholds and other strategies for guiding red blood cell transfusion.
Across 61 trials (27,639 participants), restrictive hemoglobin thresholds (7–8 g/dL) reduced red cell exposure by 42% without increasing 30‑day mortality overall. Exceptions emerged: restrictive strategy lowered mortality in gastrointestinal bleeding, while liberal strategy improved unfavorable neurologic outcomes in neurocritical patients. Transfusion reactions were more frequent with liberal strategies; pediatric findings were broadly consistent but less certain.
Impact: This high-quality Cochrane review consolidates definitive evidence to refine transfusion practices across perioperative and critical care settings, highlighting subgroup-specific nuances.
Clinical Implications: Adopt restrictive transfusion thresholds (7–8 g/dL) for most adults to reduce exposure without harming mortality, while considering liberal thresholds in neurocritical brain injury and restrictive strategies in GI bleeding. Implement stewardship to reduce transfusion reactions and explore physiologic triggers in selected contexts.
Key Findings
- Restrictive strategies reduced receipt of ≥1 RBC unit by 42% across 61 trials (RR 0.58, 95% CI 0.52–0.65).
- No overall difference in 30-day mortality between restrictive and liberal thresholds (RR 1.01, 95% CI 0.90–1.14).
- Gastrointestinal bleeding favored restrictive strategy for 30-day mortality (RR 0.63, 95% CI 0.42–0.95).
- Neurocritically ill patients had better 6–12 month neurologic outcomes with liberal strategies (RR 1.14 for unfavorable outcomes).
- Transfusion reactions were less frequent with restrictive approaches (Peto OR 0.47).
Methodological Strengths
- Large, comprehensive meta-analysis across diverse clinical settings with GRADE assessment
- Low risk of bias in most included RCTs; robust random-effects models
Limitations
- High heterogeneity in transfusion exposure outcomes (I²=97%) reflecting context diversity
- Physiologic trigger trials were heterogeneous precluding meta-analysis; pediatric certainty lower
Future Directions: Define context-specific thresholds (e.g., brain injury, acute MI), integrate physiologic triggers with hemoglobin thresholds, and prioritize patient-centered outcomes (function/quality of life) beyond mortality.
2. Effect of preoperative transcranial direct current stimulation on postoperative delirium in elderly patients following laparoscopic surgery.
In a randomized, sham-controlled trial of 201 elderly patients undergoing major laparoscopy, a single pre-induction tDCS session reduced POD incidence to 7.0% versus 22.8% with sham. Postoperative anxiety and depression scores were also lower on day 1, without differences in pain scores.
Impact: Demonstrates a feasible, nonpharmacological, and scalable neuromodulatory intervention that substantially reduces delirium—a major driver of morbidity and resource use in perioperative care.
Clinical Implications: Preoperative single-session tDCS may be integrated into perioperative pathways for high-risk elderly patients to prevent POD, potentially reducing ICU utilization, length of stay, and downstream cognitive decline. Implementation will require workflow alignment and staff training.
Key Findings
- POD incidence reduced from 22.8% (sham) to 7.0% with preoperative tDCS over 3 postoperative days.
- Postoperative day-1 anxiety and depression scores were significantly lower in the tDCS group; pain scores were similar.
- Single-session, pre-induction tDCS was operationally feasible within routine perioperative workflows.
Methodological Strengths
- Randomized, sham-controlled design with adequate sample size (n=201 analyzed)
- Clear primary endpoint with short-term follow-up suited to POD detection
Limitations
- Single-session protocol and short follow-up; durability and optimal dosing unknown
- Single-condition focus (major laparoscopy); generalizability to other surgeries requires testing
Future Directions: Dose-finding and multicenter trials across surgical types; mechanistic studies (EEG/connectivity) to identify responders; health economic evaluations for scalability.
3. Evaluation of TU-100 (Daikenchuto), a Traditional Japanese Kampo Medicine, As an Adjunct to Enhanced Recovery After Surgery, for Acceleration of Gastrointestinal Recovery After Bowel Resection - Results of a Proof-of-Concept, Phase 2, Randomized, Double-Blind, Placebo-Controlled Trial.
Among 392 patients, TU‑100 7.5 g/day showed consistent favorable trends: more patients achieved GI recovery by postoperative day 2 (78.1% vs 66.9%; p=0.047) and median length of stay was reduced (2 vs 3 days; p=0.03), with improved early nausea/bloating symptoms. The 15 g/day dose did not differ from placebo; the primary composite hazard ratio was not statistically significant.
Impact: Provides multicenter randomized evidence that a Kampo medicine can augment ERAS pathways by accelerating early GI recovery and shortening hospitalization after bowel resection.
Clinical Implications: Consider TU‑100 7.5 g/day as a potential adjunct within ERAS after bowel resection to improve early GI recovery and reduce length of stay, while recognizing dose–response uncertainty and neutral primary endpoint. Earlier initiation and dosing optimization warrant evaluation.
Key Findings
- TU‑100 7.5 g/day increased proportion achieving GI recovery by postoperative day 2 (78.1% vs 66.9%; p=0.047).
- Median length of stay was shorter with 7.5 g/day vs placebo (2 vs 3 days; p=0.03).
- Patient-reported nausea and abdominal bloating were lower early postoperatively with 7.5 g/day.
- No significant differences between 15 g/day and placebo; primary composite hazard ratio not statistically significant.
Methodological Strengths
- Randomized, double-blind, placebo-controlled Phase 2 across 36 sites
- Multiple clinically relevant secondary endpoints including patient-reported outcomes and length of stay
Limitations
- Primary endpoint did not reach statistical significance; efficacy signals concentrated in secondary outcomes
- Drug started on postoperative day 1 with short inpatient window; limited dosing exploration
Future Directions: Confirmatory Phase 3 trials with earlier perioperative initiation, dose optimization, and standardized ERAS co-interventions; mechanistic studies on motility and anti-inflammatory pathways.