Daily Anesthesiology Research Analysis
Three impactful anesthesiology studies stood out: a multicenter prospective cohort quantified the true incidence of intraoperative pain during cesarean delivery under neuraxial anesthesia; a randomized non-inferiority trial showed combined TAP and rectus sheath blocks with PCIA are non-inferior to epidural analgesia after kidney transplantation; and a large multicenter retrospective analysis found that shortening preoperative fluid fasting improves outcomes including delirium and length of stay.
Summary
Three impactful anesthesiology studies stood out: a multicenter prospective cohort quantified the true incidence of intraoperative pain during cesarean delivery under neuraxial anesthesia; a randomized non-inferiority trial showed combined TAP and rectus sheath blocks with PCIA are non-inferior to epidural analgesia after kidney transplantation; and a large multicenter retrospective analysis found that shortening preoperative fluid fasting improves outcomes including delirium and length of stay.
Research Themes
- Patient-centered outcomes and analgesia strategies in perioperative care
- Optimizing preoperative fasting to reduce delirium and resource use
- Quality and safety metrics in obstetric neuraxial anesthesia
Selected Articles
1. Combined transversus abdominis plane and rectus sheath blocks with patient-controlled intravenous analgesia versus epidural analgesia for kidney transplantation: randomized, non-inferiority clinical trial.
In a single-center randomized non-inferiority trial (n=90), TAP and rectus sheath blocks plus PCIA were non-inferior to epidural analgesia for QoR-15 on POD1 after kidney transplantation, with comparable renal function and recovery through POD7. Epidural yielded lower intraoperative MAP and opioid use and faster emergence but required longer procedure time.
Impact: This RCT provides high-quality evidence that abdominal wall blocks with PCIA can match epidural analgesia in recovery quality after kidney transplantation, offering a practical alternative where epidural is contraindicated or undesirable.
Clinical Implications: For kidney transplant recipients, TAP+RS blocks with PCIA can be considered when epidural analgesia is risky or resource-intensive, without compromising early recovery metrics. Teams should weigh hemodynamic and workflow differences when selecting techniques.
Key Findings
- POD1 QoR-15 was non-inferior with TAP+RS+PCIA vs epidural (mean difference −1.8; 95% CI −4.2 to 0.6; P<0.001 for non-inferiority).
- Renal function indices and QoR-15 on POD3 and POD7 were comparable between groups.
- Epidural group had lower intraoperative mean arterial pressure, lower opioid consumption, and faster emergence, but longer intervention time.
Methodological Strengths
- Randomized non-inferiority design with prespecified primary outcome (QoR-15).
- Clinically relevant, patient-centered endpoints with multiple postoperative timepoints.
Limitations
- Single-center trial limits generalizability.
- Blinding of interventions was not feasible; potential performance bias.
- Sample size modest for detecting rare complications.
Future Directions: Multicenter RCTs comparing cost-effectiveness, complications (e.g., hematoma, block failure), and long-term outcomes; protocolized hemodynamic strategies tailored to each technique.
2. Incidence of pain during cesarean delivery with neuraxial anesthesia: an international, prospective cohort study.
Across 15 North American centers, 7.6% of 3,693 parturients reported intraoperative pain under neuraxial anesthesia for cesarean delivery, with lower rates for spinal and higher for epidural top-up techniques. Among those with pain, median NRS was 6/10 and about 10% expressed dissatisfaction with pain management.
Impact: This large prospective study establishes a benchmark incidence of intraoperative pain by technique during cesarean delivery, informing consent, quality metrics, and choice of neuraxial approach.
Clinical Implications: Spinal anesthesia should be favored when feasible to minimize intraoperative pain risk. Counseling should include the non-zero risk of pain under neuraxial anesthesia and contingency plans for supplementation or conversion.
Key Findings
- Overall intraoperative pain incidence was 7.6% (282/3,693; 95% CI 6.8–8.5).
- Elective cases: spinal 3.7%, combined spinal–epidural 9.2%, epidural top-up 12.2%.
- Non-elective cases had higher pain rates; epidural top-up reached 13.2%. Median pain intensity among those with pain was NRS 6 (IQR 4–8).
Methodological Strengths
- Prospective, multicenter design with large sample size across 15 centers.
- Standardized postpartum day-1 patient-reported outcomes including NRS and satisfaction.
Limitations
- Self-reported pain assessed on POD1 may be subject to recall bias.
- Technique selection not randomized; potential confounding by indication.
- Limited to North American centers; generalizability may vary.
Future Directions: Identify modifiable risk factors for intraoperative pain under neuraxial anesthesia and test standardized supplementation algorithms to reduce incidence.
3. Impact of Shorter Preoperative Fluid Fasting on Patient Outcomes: A Safe Brain Initiative Retrospective Cohort Analysis.
In 15,837 adults, median fluid-fasting time was 5 hours and only 40.3% adhered to recommended 2–4 hours. Implementation efforts increased adherence over time, and shorter fasting (2–4 h) was associated with an 18-hour reduction in hospital stay, lower postoperative delirium risk, and better patient-reported outcomes.
Impact: This large multicenter analysis links guideline-concordant fluid-fasting times to meaningful reductions in delirium and hospital stay, supporting system-level fasting optimization as a high-yield perioperative quality measure.
Clinical Implications: Standardize preoperative fluid fasting to 2–4 hours, with active implementation and auditing, to reduce delirium risk and length of stay while improving patient comfort.
Key Findings
- Median fluid-fasting time was 5 h (IQR 4–8); 11.9% fasted ≥12 h; only 40.3% adhered to 2–4 h.
- Adherence to short fasting increased over time after SBI-CB implementation (r=0.7, P<0.001).
- Short fasting was associated with 18-hour shorter hospital stay (P<0.001) and reduced postoperative delirium (adjusted log-odds ~0.7 [0.6–0.8]).
Methodological Strengths
- Very large multicenter cohort with one-to-many matching and multivariable regression.
- Inclusion of patient-reported outcomes alongside clinical endpoints.
Limitations
- Retrospective design prone to residual confounding and selection bias.
- Delirium assessment limited to recovery room; fasting time documentation accuracy may vary.
- Only 4 hospitals (Denmark, Turkey); generalizability may be limited.
Future Directions: Prospective implementation trials with standardized delirium assessments and cost-effectiveness analyses to validate and scale fasting optimization.