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.
BACKGROUND: Epidural analgesia can improve early postoperative recovery after renal transplantation. Abdominal wall blocks (transversus abdominis plane (TAP) and rectus sheath (RS)) combined with patient-controlled intravenous analgesia (PCIA) have also been shown to enhance postoperative recovery. However, it remains unclear whether these techniques are as effective as epidural analgesia (EP). METHODS: In this single-centre randomized non-inferiority clinical trial, participants undergoing renal transplantation were randomly assigned to receive either a TAP + RS block (combined with PCIA) or EP alone. The primary outcome was Quality of Recovery-15 (QoR-15) scores on postoperative day (POD) 1. Secondary outcomes included haemodynamics, indices of postoperative renal function, time to interventions, and postoperative pain scores. RESULTS: Ninety participants were included in the analysis. The TAP + RS group demonstrated non-inferiority to the EP group in terms of the mean(standard deviation) total QoR-15 score on POD1 (90.6(5.0) versus 92.4(6.4); mean difference, -1.8; 95% confidence interval -4.2 to 0.6; P < 0.001 for non-inferiority). QoR-15 scores on POD3 and POD7 and indices of postoperative renal function were comparable between the two groups, with no group-time interactions. The EP group had significantly lower mean arterial pressure and intraoperative opioid consumption, as well as shorter times to eye opening and extubation, than the TAP + RS group. However, the intervention time was longer in the EP group (P < 0.001). CONCLUSION: TAP + RS block combined with PCIA demonstrated non-inferiority to EP for postoperative QoR-15 scores after kidney transplantation. TAP + RS block offers a potentially more convenient and favourable alternative to EP, helping maintain haemodynamic stability, postoperative renal function, and a low complication profile. REGISTRATION NUMBER: ChiCTR2200056455 (https://www.chictr.org.cn).
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.
BACKGROUND: Neuraxial anesthesia techniques are considered the preferred technique for cesarean delivery, however the true incidence of pain during cesarean delivery with neuraxial anesthesia is not currently known. To date studies have been retrospective or conducted in a single center. The primary aim of this international cohort study was to prospectively determine the incidence of patient reported pain during cesarean delivery with neuraxial anesthesia. METHODS: We conducted, over 8 weeks, a multicenter cohort study in 15 centers across the United States of America and Canada; all patients who underwent cesarean delivery with neuraxial anesthesia were surveyed on postpartum day 1 regarding the presence of intraoperative pain, grade their pain using a numeric rating score (0-10) and rate their satisfaction (Yes/No) with their pain management.. RESULTS: A total of 3,693 patients were included in the analysis. An overall incidence of patient reported pain during cesarean delivery was 7.6% (95% CI 6.8%, 8.5%) with 282 of 3,693 patients reporting pain. In patients undergoing elective cesarean delivery, intraoperative pain was reported in 3.7% (95% CI 2.7%, 5.0%) with spinal, 9.2% (95% CI 6.7%, 12.2%) with combined spinal-epidural and 12.2% (95% CI 4.1%, 26.2%) with epidural top-up anesthesia. In the non-elective setting, pain was more commonly reported by patients, 5.7% (95% CI 4.0, 7.8) with spinal, 7.1% (95% CI 4.7%, 10.1%) with combined spinal-epidural, 8.0% (95% CI 2.2%, 19.2%) with dural puncture epidural and 13.2% (CI 95% CI 11.1%, 15.5%) with epidural top-up anesthesia. Patients who had intraoperative pain reported a median (IQR) numeric rating score of 6 (4-8) out of 10. In those who reported pain, dissatisfaction with how the pain was managed by the anesthesia team was reported by 29 (10.3%) patients. CONCLUSIONS: Overall incidence of patient reported pain during cesarean delivery with neuraxial anesthesia in this multicenter cohort was 7.6%. This varied significantly by anesthesia technique, with spinal having the lowest incidence and epidural top-up the highest. Further work is required to characterize the pain experience, understand its impact, and develop techniques to reduce its 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.
BACKGROUND: Preoperative fasting practices can influence patient outcomes. Prolonged fasting can occur due to unclear instructions, misunderstandings, anxiety, and scheduling uncertainty. The aim of this study was to determine preoperative fluid-fasting time (FFT) in clinical practice and to assess how shorter FFT could impact patients and healthcare resources. METHODS: A multicenter, retrospective observational analysis including 15,837 patients extracted from the Safe Brain Initiative care bundle (SBI-CB) database is presented. A part of the SBI-CB was to encourage FFT to be reduced to 2 hours as per guidelines. Four hospitals from Denmark and Turkey participated. Patients were >18 years old, scheduled for surgery, and able to communicate with healthcare staff. The primary outcomes were FFT, in hours, and the proportion of patients adherent to short FFT (2-4 hours) per month since the SBI-CB was initiated at each hospital. Secondary outcomes, comparing short with long (5-24 hours) FFT, included postoperative delirium in the recovery room, hospital length of stay in hours, and patient-reported outcome measures (PROMs) including thirst, pain, nausea/vomiting, stress/anxiety, and well-being. Sex, age, American Society of Anesthesia Physical Status Classification System category, surgery time, and use of general anesthesia were controlled for confounding effects by a one-to-many patient matching. Logistic and linear regressions were performed to adjust for the same confounding effects in addition to delirium at induction and site for the outcomes postoperative delirium and hospital stay. RESULTS: Median (Q1-Q3) FFT was 5 (4-8) hours with a mean of 6.3 hours. 40.3% of patients adhered to the short FFT protocol of 2 to 4 hours. Prolonged FFT of at least 12 hours was experienced by 11.9% of patients. A significant positive correlation between SBI-CB implementation month and adherence to short FFT was observed (r = 0.7, P < .001). When comparing matched patients with short and long FFT, median hospital stay was significantly reduced by 18.0 hours (P < .001). Using logistic regression, short FFT was associated with a significant reduction in postoperative delirium with a log odds ratio [95% confidence interval] of 0.7 [0.6-0.8], P < .001. All measured PROMs were improved significantly with most benefits observed postoperatively. CONCLUSION: Adherence to a short FFT could be increased over time; however, many patients still experienced an FFT that should be considered too long. Implementation of short FFT was linked to enhanced patient outcomes and more efficient healthcare resource utilization. These findings underscore the importance of optimizing preoperative fasting practices to improve patient care and healthcare efficiency.