Daily Anesthesiology Research Analysis

BACKGROUND: Hydroxyethyl starch (HES) is often used for maintaining vascular volume during major surgery. Long-term high-dose HES in septic patients promotes renal injury, whereas meta-analyses of current HES products in surgical patients do not show such effects. OBJECTIVE: We studied if the peri-operative use of HES is noninferior to crystalloids in terms of acute kidney injury. Secondary outcome was the noninferiority of HES on worsening of renal injury and/or the incidence of a composite endpoint of major complications and mortality until postoperative day 90. DESIGN: Randomised double-blind trial in patients undergoing elective abdominal surgery with expected blood loss at least 500 ml. SETTING: Multicentre trial at 53 study sites in 10 European countries. PATIENTS: One thousand nine hundred and eighty-five (HES 977, crystalloid-only 981) patients aged 40 to 85 years with ASA status II-III. INTERVENTION: Either 6% HES 130/0.4 or a crystalloid solution. Dosing was guided by mean arterial pressure and/or routine haemodynamic variables. MAIN OUTCOME MEASURE: Change from pre-operative to lowest cystatin C-based eGFR during the first 3 postoperative days. Key secondary outcome was a composite endpoint of mortality and major postoperative complications after 90 days. RESULTS: Mean change in eGFR from baseline to minimum was -3.4 ± 17.7 ml min -1  1.73 m -2 in HES patients and -1.0 ± 17.1 ml min -1 1.73 m -2 in crystalloid-only patients ( P  < 0.001 for noninferiority). The key secondary endpoint occurred in 35% of patients in each group. There were no clinically relevant differences in any safety endpoint including 90-day renal function. Any cause mortality-difference until the end of 1-year follow-up was not significantly different (8.6% in HES and 10.1% in crystalloid patients). CONCLUSION: Peri-operative use of HES was noninferior to crystalloids in short-term renal function or a composite of mortality and major complications at 90 days. PHOENICS provides robust evidence that peri-operative in-label use of HES is well tolerated. TRIAL REGISTRATION AND FUNDING: EudraCT no. 2016-002162-30, clinicaltrials.gov ID NCT03278548.

BACKGROUND: Esmolol, an ultra-short-acting β1-selective adrenergic antagonist, has been investigated for its potential opioid-sparing effects in multimodal anesthesia. Previous systematic reviews included trials with different control groups causing severe limitations to the generalization of the findings. This systematic review and meta-analysis exclusively synthesized placebo-controlled randomized trials to evaluate the impact of intraoperative esmolol infusion on opioid consumption and postoperative pain scores within the first 24 hours after surgery. METHODS: A systematic search was conducted in Medline, Embase, Cochrane Library, and Google Scholar to identify randomized placebo-controlled trials assessing the effects of continuous intraoperative esmolol infusion on opioid consumption and pain scores. The outcomes of interest were total intraoperative and postoperative opioid consumption, converted to intravenous morphine milligram equivalents (IV MME), and pain intensity, and assessed using either the visual analog scale (VAS) or the Numeric Rating Scale (NRS), both of which were standardized using validated methods to a common 0 to 10 scale. Meta-analyses were performed using a random-effects model, and heterogeneity was assessed using Cochran's Q test and I² statistics. Meta-regression and subgroup analyses explored the effects of esmolol infusion rate, type of surgery, intraoperative anesthetic and hemodynamic management, and patient age as potential moderators. RESULTS: Nineteen randomized trials (1028 patients) were included, involving esmolol regimens with a loading dose ranging from 0.5 to 1.0 mg/kg and a maintenance infusion rate of 0.3 to 6 mg/kg/h. Surgical procedures ranged from minimally invasive to open intracavitary surgeries. Esmolol infusion significantly reduced in 32% the intraoperative opioid consumption (mean differences [MD], -12.89 IV MME; 95% Confidence Interval, 95% confidence interval [CI], -24.74 to -1.05; P < .001; I² = 93.6%) and 38.6% the postoperative opioid consumption (MD, -3.03 IV MME; 95% CI, -4.29 to -1.76; P < .001; I² = 89.9%). For pain scores, 3 analyses were performed at the following intervals: within 30 minutes (MD, -1.47; 95% CI, -2.02 to -0.93; P < .001), between 2 and 4 hours (MD, -0.67; 95% CI, -1.29 to -0.06; P = .032), and at 24 hours (MD, -0.48; 95% CI, -0.92 to -0.03; P =.038). Based on the weighted mean values for the placebo group in each pooled analysis, we observed reductions in pain scores of 27.3%, 15.8%, and 23.5%, respectively. In addition, esmolol significantly reduced intraoperative heart rate in most cases and lowered MAP at multiple time points in several studies. Despite this, no significant increase in hypotension or bradycardia was reported, and only 1 study noted higher ephedrine and atropine use. CONCLUSIONS: Esmolol infusion significantly reduces opioid consumption and postoperative pain, with a magnitude of effect that may have clinical significance. The observed effects remained consistent in subgroups where confounding variables, expected to bias the results toward the null, were present. However, the uncertainty in later pain outcomes and the persistent heterogeneity warrant further research into esmolol's applicability across different surgical contexts and populations.

BACKGROUND: Intraoperative hypotension, defined as a mean arterial pressure (MAP) of less than 65 mmHg, is a major concern in pancreaticoduodenectomy, particularly in elderly patients, due to its association with adverse postoperative outcomes. Hypotension Prediction Index (HPI) could predict intraoperative hypotension. We tested the hypothesis that HPI reduces intraoperative hypotension in these patients. METHODS: This randomized trial enrolled 60 patients aged ≥65 years undergoing elective pancreaticoduodenectomy. Patients were randomly assigned to receive either HPI-guided hemodynamic management (intervention) or no HPI guidance (control) in a 1:1 ratio. Intraoperative hypotension treatment was initiated when HPI exceeded 85 (intervention) or MAP fell below 65 mmHg (control). The primary outcome was the time-weighted average (TWA) MAP <65 mmHg. Secondary outcomes included duration of hypotension, intraoperative and postoperative metrics, fluid and blood product use, vasoactive dose, and 30-day postoperative complications and mortality. RESULTS: The intervention group had a significantly lower TWA MAP <65 mmHg value than the control group (0.02 mmHg [IQR, 0-0.11 mmHg] vs. 0.23 mmHg [0.12-0.73 mmHg], p < 0.001). There were no significant between-group differences in the use of fluids and blood products or in the dose of vasoactive drugs. However, the intervention group had fewer postoperative pulmonary and gastrointestinal complications than the control group. There was one death in each group. CONCLUSIONS: The use of HPI significantly reduces intraoperative hypotension in elderly patients undergoing pancreaticoduodenectomy, leading to a reduction in pulmonary and gastrointestinal complications. Further research is needed to assess its impact on overall postoperative morbidity and mortality.