Daily Anesthesiology Research Analysis
Two randomized clinical trials inform perioperative practice: a non-inferiority trial shows anterior quadratus lumborum block at the lateral supra-arcuate ligament provides analgesia comparable to thoracic paravertebral block after laparoscopic nephrectomy, and a dosing trial demonstrates that titrated sugammadex reduces drug use without increasing residual paralysis. A global systematic analysis underscores that sepsis incidence and mortality surged in 2020–2021, with substantial burden in olde
Summary
Two randomized clinical trials inform perioperative practice: a non-inferiority trial shows anterior quadratus lumborum block at the lateral supra-arcuate ligament provides analgesia comparable to thoracic paravertebral block after laparoscopic nephrectomy, and a dosing trial demonstrates that titrated sugammadex reduces drug use without increasing residual paralysis. A global systematic analysis underscores that sepsis incidence and mortality surged in 2020–2021, with substantial burden in older adults, reinforcing priorities for anesthesia-critical care systems.
Research Themes
- Regional anesthesia optimization for abdominal urologic surgery
- Rational neuromuscular blockade reversal dosing and monitoring
- Global sepsis burden and priorities for anesthesia-critical care
Selected Articles
1. Anterior quadratus lumborum block at the lateral supra-arcuate ligament versus thoracic paravertebral block for postoperative analgesia after laparoscopic nephrectomy: a randomized non-inferiority trial.
In this randomized non-inferiority trial (n=80), anterior QLB-LSAL provided 24-hour postoperative analgesia comparable to TPVB after laparoscopic nephrectomy. The mean VAS difference was 0.13 (95% CI 0.02–0.25), meeting the non-inferiority margin; TPVB had a larger early cutaneous sensory block area.
Impact: Provides level I evidence supporting a newer, potentially simpler regional technique as an alternative to TPVB for nephrectomy analgesia, which may broaden options in ERAS pathways.
Clinical Implications: Anterior QLB-LSAL can be considered as an alternative to TPVB for laparoscopic nephrectomy analgesia, particularly where paravertebral placement is challenging; protocols should account for slightly smaller early sensory block area.
Key Findings
- Mean 24-hour postoperative VAS: QLB-LSAL 1.92±0.28 vs TPVB 1.79±0.25; mean difference 0.13 (95% CI 0.02–0.25), meeting non-inferiority.
- TPVB produced a significantly greater cutaneous sensory block area at 10 and 30 minutes.
- Both techniques used identical local anesthetic volume/concentration (20 mL of 0.5% ropivacaine) and achieved effective analgesia.
Methodological Strengths
- Prospective randomized non-inferiority design with pre-specified primary endpoint.
- Trial registration and standardized block dosing and assessment.
Limitations
- Single-center trial with modest sample size (n=80), limiting generalizability.
- Incomplete reporting of some secondary outcomes in the abstract (e.g., sufentanil consumption specifics).
Future Directions: Multicenter trials comparing QLB-LSAL with TPVB across diverse surgeries and patient populations, including safety endpoints and opioid-sparing metrics, are warranted.
BACKGROUND: This study compared the analgesic effects of the anterior quadratus lumborum block at the lateral supra-arcuate ligament (QLB-LSAL) and thoracic paravertebral block (TPVB) for laparoscopic nephrectomy to verify whether the new quadratus lumborum block is an efficient technique for managing laparoscopic nephrectomy pain as an alternative to TPVB. METHODS: This study was a prospective randomized noninferiority clinical trial. Before general anaesthesia, 80 participating patients were randomly allocated to receive QLB-LSAL (20 mL of 0.5% ropivacaine) or TPVB (20 mL of 0.5% ropivacaine). The primary outcome was the mean visual analogue scale (VAS) score in the first 24-hafter surgery. The secondary outcomes included the cutaneous sensory block area, intraoperative haemodynamic changes, consumption of sufentanil at 24-h postoperatively, and postoperative recovery data. RESULTS: The mean VAS score during the first 24-h was 1.92 ± 0.28 in the QLB-LSAL group and 1.79 ± 0.25 in the TPVB group. The mean treatment difference (QLB-LSAL-TPVB) in the primary outcome was 0.13 (95% CI 0.02 to 0.25). The upper limit of the 95% CI remained below the non-inferiority margin. After 10 and 30 min, the TPVB group had significantly greater cutaneous sensory block area ( CONCLUSIONS: At 24-h postoperatively, QLB-LSAL had analgesic effects that were not inferior to those of TPVB for patients undergoing laparoscopic nephrectomy. TRIAL REGISTRATION: Chinese Clinical Trial Registry website; registration number: ChiCTR2100048226.
2. Global, regional, and national sepsis incidence and mortality, 1990-2021: a systematic analysis.
Using GBD 2021 data and hospital records, the study estimated 166 million sepsis cases and 21.4 million deaths globally in 2021, with a reversal of prior declines during 2020–2021. The burden is greatest in older adults and increasingly arises as a complication of non-infectious underlying diseases via bloodstream and lower respiratory infections.
Impact: Defines contemporary sepsis burden with age- and syndrome-specific resolution, guiding anesthesia-critical care resource planning and prioritization after the COVID-19 era.
Clinical Implications: Anesthesia and ICU teams should anticipate higher sepsis risk in older patients and those with major non-infectious comorbidities; perioperative screening, prevention (e.g., pulmonary hygiene), and surge capacity planning are reinforced.
Key Findings
- In 2021, an estimated 166 million sepsis cases and 21.4 million sepsis-related deaths occurred globally, accounting for 31.5% of all deaths.
- Declines in sepsis mortality from 1990 to 2019 reversed in 2020–2021, with increased burden in individuals aged ≥15 years, especially ≥70 years.
- Sepsis increasingly complicates non-infectious underlying causes of death (e.g., stroke, COPD, cirrhosis), driven by bloodstream and lower respiratory infections.
Methodological Strengths
- Integration of multiple high-volume data sources (149 million deaths; 250 million admissions) across 4290 location-years.
- Age-location-sex-specific modeling with explicit and implicit sepsis capture and syndrome attribution.
Limitations
- Model-based estimates rely on underlying data quality and assumptions; some regions may have sparse or biased data.
- Not an interventional study; cannot infer causal effects or patient-level risk modifiers.
Future Directions: Improve sepsis surveillance and coding accuracy, incorporate microbiology and antimicrobial resistance data, and link estimates to health system performance and outcomes to inform targeted interventions.
BACKGROUND: The global burden of sepsis, a life-threatening dysregulated host response to infection leading to organ dysfunction, remains challenging to quantify. We aimed to comprehensively estimate the global, regional, and national burden of sepsis, including the impact of the COVID-19 pandemic and underlying causes of sepsis-related deaths with co-occurring infectious syndromes. METHODS: We used multiple cause-of-death, hospital, minimally invasive tissue sampling, and linked death certificate and hospital record data representing 149 million deaths, covering 4290 location-years with mortality estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 to capture explicit and implicit sepsis cases and deaths. We estimated age-location-sex-specific fractions of sepsis-related deaths from 195 underlying causes of death and 22 infectious syndromes from 1990 to 2021 using binomial logistic regression models, and estimated sepsis-related deaths using GBD cause-specific mortality estimates. Using 250 million hospital admissions and 7·82 million deaths from hospital data, representing 1310 location-years, we modelled case fatality rates by use of binomial logistic regression, applied to sepsis death estimates to estimate sepsis incidence by age, location, and year. FINDINGS: In 2021, we estimated 166 million (95% uncertainty interval 135-201) sepsis cases and 21·4 million (20·3-22·5) all-cause sepsis-related deaths globally, representing 31·5% of total global deaths. Sepsis-related deaths decreased between 1990 and 2019, followed by a surge in 2020 and 2021. As of 2021, individuals aged 15 years and older experienced increases across incidence (230%) and mortality (26·3%) since 1990. Those aged 70 years and older had the highest sepsis-related mortality in 2021 (9·28 million [8·74-9·86] deaths). Sepsis-related deaths from infectious underlying causes decreased from 11·8 million (11·1-12·5) in 1990 to 8·34 million (7·72-9·01) in 2019, then increased by 86·4% to 15·5 million (14·7-16·4) in 2021. Sepsis-related mortality due to non-infectious underlying causes of death increased from 4·69 million (4·35-5·05) in 1990 to 5·81 million (5·40-6·25) in 2021; the leading non-infectious underlying causes of death with sepsis were stroke, chronic obstructive pulmonary disease, and cirrhosis. In 2021, bloodstream infections inclusive of HIV and malaria (3·08 million [2·83-3·35]) and lower respiratory infections inclusive of COVID-19 (11·33 million [1·20-1·47]) were the most prominent infectious syndromes complicating sepsis-related deaths from non-infectious underlying causes, representing a consistent trend since 1990. INTERPRETATION: The global burden of sepsis increased in 2020 and 2021, reversing progress from 1990. Sepsis incidence and mortality increased in people aged 15 years and older, especially those aged 70 years and older, and as a complication of non-infectious underlying causes of death such as stroke, primarily through bloodstream infections and lower respiratory infections. The global burden of sepsis is substantial, and sepsis is increasingly a complication of non-infectious causes of death. FUNDING: Gates Foundation, Wellcome Trust, and Department of Health and Social Care using UK aid funding managed by the Fleming Fund.
3. Effect of sugammadex titration versus manufacturer's recommendation for reversal of rocuronium-induced neuromuscular block: a prospective, randomized, controlled trial.
In a randomized controlled trial (n=205 analyzed), titrated sugammadex dosing (50 mg increments) achieved TOFR ≥0.9 with significantly less total drug than manufacturer-recommended single doses, without increasing residual paralysis. Recovery time was longer with titration, but extubation time and PACU stay were similar.
Impact: Supports dose individualization guided by quantitative neuromuscular monitoring, potentially reducing drug costs and exposure without compromising safety.
Clinical Implications: Adopt quantitative TOF monitoring to titrate sugammadex rather than defaulting to weight-based boluses; ensure postoperative monitoring for residual paralysis given interpatient variability.
Key Findings
- Titrated dosing required significantly less sugammadex to achieve TOFR ≥0.9 compared with manufacturer-recommended dosing (P<0.001).
- Incidence of residual paralysis was similar between groups (5.4% vs 4.9%).
- Recovery time was longer with titration, but extubation time and PACU length of stay did not differ.
Methodological Strengths
- Prospective randomized controlled design with continuous quantitative neuromuscular monitoring.
- Trial registration and clear, clinically meaningful outcomes (TOFR ≥0.9, residual paralysis).
Limitations
- Blinding status not detailed; potential performance bias.
- Longer recovery time with titration may affect workflow in some settings.
Future Directions: Cost-effectiveness analyses across case mixes; explore titration algorithms incorporating depth of block and pharmacokinetic modeling; assess outcomes in high-risk populations.
BACKGROUND: Both under-dosing and over-dosing of sugammadex for reversing neuromuscular block pose risks to patients, yet the optimal dosage for different degrees of neuromuscular block remains undefined. This study compared titration with single bolus of sugammadex recommended by manufacturer to determine the optimal dose for achieving a train-of-four ratio (TOFR) of 0.9 or greater while minimizing residual paralysis. METHODS: Patients were randomly assigned to titrated group or manufacturer-recommended group. In titrated group, sugammadex was given in 50-mg increments every 5 min until a TOFR of 0.9 or greater was reached. In recommended group, a single dose (2 mg/kg or 4 mg/kg) was given based on train-of-four count (TOFC). Neuromuscular block was monitored continuously, and residual paralysis was assessed in the post-anesthesia care unit (PACU). RESULTS: Of 210 enrolled patients, 205 were evaluated. The median dose of sugammadex for reversing different depths of neuromuscular block induced by rocuronium was ascertained via the titration method in this study. Titrated group required significantly less sugammadex to achieve a TOFR of at least 0.9 compared to recommended group (P < 0.001). Residual paralysis incidence was similar between groups (5.4% in titrated group vs. 4.9% in recommended group; P = 0.564). Although recovery time was longer in titrated group, extubation time and length of stay in the PACU were comparable. CONCLUSIONS: Titrated sugammadex administration significantly reduces required dosage without increasing residual paralysis risk. Continuous neuromuscular monitoring postoperatively is strongly recommended due to individual variability in dosage needs. TRIAL REGISTRATION: The study was registered in the Chinese Clinical Trial Registry on March 4, 2024(ChiCTR2400081540).