Daily Anesthesiology Research Analysis
Three high-impact critical care studies relevant to anesthesiology and intensive care emerged: a multicenter RCT showed that a personalized capillary refill time–targeted resuscitation strategy modestly improved a hierarchical outcome in early septic shock; a large international cluster RCT found no mortality benefit of selective digestive decontamination (SDD) in ventilated ICU patients while raising ecological concerns; and a global, data-driven update of the SOFA score (SOFA-2) improved predi
Summary
Three high-impact critical care studies relevant to anesthesiology and intensive care emerged: a multicenter RCT showed that a personalized capillary refill time–targeted resuscitation strategy modestly improved a hierarchical outcome in early septic shock; a large international cluster RCT found no mortality benefit of selective digestive decontamination (SDD) in ventilated ICU patients while raising ecological concerns; and a global, data-driven update of the SOFA score (SOFA-2) improved predictive validity and modernized organ dysfunction thresholds.
Research Themes
- Personalized hemodynamic resuscitation in septic shock
- Infection control strategies and ecological impact in the ICU
- Modernization and validation of organ dysfunction scoring (SOFA-2)
Selected Articles
1. Personalized Hemodynamic Resuscitation Targeting Capillary Refill Time in Early Septic Shock: The ANDROMEDA-SHOCK-2 Randomized Clinical Trial.
In a 19-country multicenter RCT of early septic shock, a CRT-targeted personalized hemodynamic protocol achieved a significant win ratio (1.16) over usual care on a 28-day hierarchical composite outcome. The benefit was driven mainly by fewer days requiring vasoactive support, mechanical ventilation, and kidney replacement therapy.
Impact: This trial provides high-level evidence that a simple bedside perfusion target (CRT) embedded in a personalized protocol can improve clinically meaningful composite outcomes in septic shock.
Clinical Implications: Adopting CRT-guided personalized resuscitation may reduce exposure to vasoactives, ventilation, and kidney support in early septic shock. Implementation requires protocolized assessment of pulse pressure, diastolic pressure, fluid responsiveness, and point-of-care echocardiography.
Key Findings
- Win ratio of 1.16 (95% CI 1.02–1.33; P=0.04) favoring CRT-personalized resuscitation for the 28-day hierarchical composite.
- Primary benefit components: reduced duration of vital support (vasoactives, mechanical ventilation, kidney replacement therapy).
- Trial spanned 86 centers in 19 countries; stratification by APACHE II supported robustness across illness severity.
Methodological Strengths
- Multicenter randomized design with global enrollment and protocolized personalized assessment.
- Use of a hierarchical composite and win ratio to capture clinically meaningful differences beyond mortality alone.
Limitations
- Open-label pragmatic design with potential variability in usual care across centers.
- Effect largely on support duration; individual mortality differences were not the main driver.
Future Directions: Evaluate mortality-focused endpoints, cost-effectiveness, and integration with other perfusion/echocardiographic targets; assess implementation fidelity and training needs.
2. Selective Decontamination of the Digestive Tract during Ventilation in the ICU.
In a large international cluster randomized trial, SDD did not reduce 90-day in-hospital mortality among mechanically ventilated ICU patients. Although patient-level microbiology suggested fewer bloodstream infections and fewer cultured antibiotic-resistant organisms with SDD, the ecologic noninferiority threshold for resistant organisms was not met.
Impact: This definitive trial informs a decades-long debate by showing no mortality benefit of SDD and raises unresolved ecological concerns, directly impacting ICU infection control policies.
Clinical Implications: Routine SDD to reduce mortality in ventilated ICU patients is not supported. Centers considering SDD must weigh potential reductions in bloodstream infections against uncertain ecological risks and the inability to confirm noninferiority regarding resistant organisms at the unit level.
Key Findings
- No difference in 90-day in-hospital mortality: 27.9% (SDD) vs 29.5% (standard care), OR 0.93 (95% CI 0.84–1.05; P=0.27).
- SDD group had fewer new bloodstream infections (adjusted mean difference −1.30 percentage points) and fewer cultured antibiotic-resistant organisms (−9.60 percentage points) at the patient level.
- In the ecologic assessment, noninferiority for new antibiotic-resistant organisms was not confirmed, leaving ecological safety unresolved.
Methodological Strengths
- Large, rigorous cluster randomized cross-over design across 26 ICUs with concurrent ecological surveillance.
- Prespecified patient-level and ecological outcomes allow balanced assessment of efficacy and potential harms.
Limitations
- Heterogeneity in standard care and antimicrobial ecology across sites may influence generalizability.
- Ecologic noninferiority was not achieved; longer-term or broader ecological consequences remain uncertain.
Future Directions: Further work should refine ecological endpoints and surveillance, evaluate targeted SDD strategies or alternatives, and assess antimicrobial stewardship interactions and cost-effectiveness.
3. Development and Validation of the Sequential Organ Failure Assessment (SOFA)-2 Score.
Using over 3.3 million ICU encounters across 9 countries, SOFA-2 updated variables and thresholds for six organ systems and improved AUROC (0.79 vs 0.77 for legacy SOFA) on ICU day 1, with sustained predictive validity through day 7. Gastrointestinal and immune subscores were not incorporated due to insufficient data and content validity.
Impact: SOFA-2 modernizes the most widely used organ dysfunction score, aligning it with contemporary ICU practices and improving predictive performance, with potential to standardize endpoints and risk adjustment in trials and clinical care.
Clinical Implications: SOFA-2 can be adopted for early risk stratification, prognosis, and trial enrollment/stratification, reflecting current organ support modalities. Implementation should consider training and EHR integration; cross-setting calibration may be necessary.
Key Findings
- SOFA-2 improved AUROC on ICU day 1 to 0.79 (95% CI 0.76–0.81) versus legacy SOFA 0.77 (95% CI 0.74–0.81).
- Updated variables and thresholds across brain, respiratory, cardiovascular, liver, kidney, and hemostasis systems; predictive validity maintained across ICU days 1–7.
- Gastrointestinal and immune subscores were not included due to insufficient data and content validity.
Methodological Strengths
- Massive federated, multicountry datasets for development and external validation.
- Combined expert consensus (modified Delphi) with data-driven thresholding for content and predictive validity.
Limitations
- Observational data cannot establish causal impacts of score-guided decisions.
- Gastrointestinal and immune dysfunctions were not incorporated; implementation and calibration needs remain.
Future Directions: Prospective validation for clinical decision support, evaluation of responsiveness to interventions, and assessment of global calibration across resource settings.