Daily Anesthesiology Research Analysis

BACKGROUND: The benefit-risk profile of systemic corticosteroids in non-COVID-19 pneumonia and acute respiratory distress syndrome (ARDS) remains debated. PURPOSE: To assess corticosteroid effects on mortality and infection-related complications in adults with severe pneumonia or ARDS. DATA SOURCES: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform through September 2025. STUDY SELECTION: Randomized controlled trials comparing systemic corticosteroids with placebo and usual care. Primary analysis: severe pneumonia or ARDS with corticosteroids 3 mg/kg DATA EXTRACTION: Paired reviewers; consensus for disagreements. DATA SYNTHESIS: From 16 831 screened records, 20 studies (15 severe pneumonia, 5 ARDS) including 3459 participants met criteria. Low-dose, short-course corticosteroids probably reduce short-term mortality in severe pneumonia (15 studies, 2445 participants; risk ratio [RR], 0.73 [95% CI, 0.57 to 0.93]; LIMITATION: Heterogeneous pneumonia severity classification limiting subgroup precision. CONCLUSION: In severe pneumonia and ARDS, adjunct corticosteroids probably reduce short-term mortality. In severe pneumonia, they may reduce secondary shock. In both conditions, corticosteroids may have little or no effect on hospital-acquired infections. PRIMARY FUNDING SOURCE: None. (PROSPERO: CRD42024536301).

IMPORTANCE: Levosimendan may facilitate weaning from venoarterial extracorporeal membrane oxygenation (VA-ECMO) and improve survival, but supporting evidence remains limited. OBJECTIVE: To assess whether early administration of levosimendan reduces the time to successful VA-ECMO weaning in patients with severe but potentially reversible cardiogenic shock. DESIGN, SETTING, AND PARTICIPANTS: Randomized, double-blind, placebo-controlled trial conducted across 11 intensive care units (ICUs) in France. Between August 27, 2021, and September 10, 2024, 205 adult patients with acute cardiogenic shock who had started VA-ECMO in the preceding 48 hours were enrolled. Final follow-up was completed on November 10, 2024. INTERVENTIONS: Patients were randomized in a 1:1 ratio to receive levosimendan, 0.15 μg/kg per minute, to be increased to 0.20 μg/kg per minute after 2 hours (n = 101), or placebo (n = 104). MAIN OUTCOMES AND MEASURES: The primary outcome was time to successful ECMO weaning within 30 days following randomization. Secondary outcomes included ECMO-, mechanical ventilation-, and organ failure-free days, ICU and hospital lengths of stay, serious adverse events, and all-cause 30- and 60-day mortality. RESULTS: Among the 205 randomized patients (median age, 58 [IQR, 50-67] years; 149 [72.7%] male), main cardiogenic shock etiologies were postcardiotomy (79 [38.5%]), acute myocardial infarction (56 [27.3%]), and myocarditis (28 [13.7%]). Treatment dose was increased to 0.20 ± 0.01 μg/kg per minute in 93% of patients receiving levosimendan and in 96% of those receiving placebo. Within 30 days, 69 of 101 patients (68.3%) had a successful ECMO weaning in the levosimendan group compared with 71 of 104 (68.3%) in the placebo group (risk difference, 0.0% [95% CI, -12.8% to 12.7%]; subdistribution hazard ratio, 1.02 [95% CI, 0.74-1.39]; P = .92). In the levosimendan and placebo groups, respectively, median ECMO duration (5 [IQR, 4-7] days vs 6 [IQR, 4-11] days; P = .53), mean ICU length of stay (18 [SD, 15] days vs 19 [SD, 15] days; P = .42), and 60-day mortality (27.7% vs 25.0%; risk difference, 2.7% [95% CI, -9.0% to 15.3%]; P = .78) did not differ significantly. Ventricular arrhythmias occurred more frequently with levosimendan (18 [17.8%] vs 9 [8.7%]; absolute risk difference, 9.2% [95% CI, 0.4%-18.1%]). CONCLUSIONS AND RELEVANCE: Among patients with severe but potentially reversible cardiogenic shock supported by VA-ECMO, early levosimendan administration did not significantly reduce the time to successful weaning of ECMO compared with placebo. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04728932.

BACKGROUND: Endotracheal tubes with subglottic ports and a polyurethane cuff are recommended for reducing microaspiration in patients who are ventilated. However, their long-term safety and efficacy after emergency intubation are uncertain. METHODS: In this randomised controlled phase 2 trial conducted at two single centres (Oregon Health and Science University [OHSU, Portland, OR, USA] and Yale New Haven Hospital [YNHH, New Haven, CT, USA]), all patients aged 18 years or older requiring endotracheal intubation either in the emergency department or elsewhere in hospital for acute respiratory distress or failure were randomly assigned to receive a polyurethane-cuffed endotracheal tube with subglottic suction (PU-EVAC) or a polyvinylchloride-cuffed endotracheal tube (PVC). Individuals who were electively intubated in the operating room and protected populations (children [aged younger than 18 years], pregnant women, and prisoners) were ineligible to participate. Patients were randomised 1:1 into the two treatment arms using a fair coin randomisation scheme. Patients assigned to the PVC group were treated according to usual care, and patients assigned to the PU-EVAC group received continuous subglottic suctioning until removal of the endotracheal tube. The coprimary endpoints at 6 months were laryngeal injury, quality of life (Short Form-36 [SF-36] physical component summary [PCS] and mental component summary [MCS] scores), and cognitive function. Secondary endpoints were infection-related ventilator-associated complications (IVAC) and possible ventilator-associated pneumonia (VAP). This trial is registered at ClinicalTrials.gov (NCT03705286) and is now completed. FINDINGS: Between May 6, 2019, and July 31, 2019 (Oregon Health and Science University), and Sept 29, 2020, to Feb 11, 2022 (Yale New Haven Hospital), 1074 adult patients were enrolled and 1068 were randomly assigned to either the PVC (n=533) or the PU-EVAC (n=535) endotracheal tube group. Participants had a mean age at intubation of 62·9 years (SD 15·7), were mostly male (671 [63%] of 1068), and mostly White (718 [67%]). IVAC occurred in 43 (8%) of 535 patients in the PU-EVAC group and in 33 (6%) of 533 patients in the PVC group (risk difference 0·02 [95% CI -0·01 to 0·05]); possible VAP occurred in 30 (6%) patients in the PU-EVAC group and 24 (5%) patients in the PVC group (0·01 [-0·02 to 0·04]). At 6-month follow-up, 558 patients had died (274 [51%] in the PU-EVAC group and 284 [53%] in the PVC group). 157 completed the 6-month follow-up visit. Laryngeal injury was reported in 71 (83%) of 86 patients in the PU-EVAC group and in 49 (70%) of 70 patients in the PVC group (0·11 [-0·03 to 0·20]; p=0·098). Mean PCS was 39·97 (SD 10·97) in the PU-EVAC group and 40·49 (11·92) in the PVC group (mean difference -0·52 [95% CI -4·21 to 3·17]; p=0·78) and mean MCS was 45·91 (13·10) in the PU-EVAC group and 48·89 (12·22) in the PVC group (-2·98 [-7·03 to 1·07]; p=0·15). Cognitive impairment was present in 70 (85%) of 82 in the PU-EVAC group and 54 (81%) of 67 patients in the PVC group (risk difference 0·05 [-0·07 to 0·17]; p=0·44). INTERPRETATION: The PU-EVAC did not reduce the incidence of IVAC or possible VAP compared with a standard PVC endotracheal tube with no subglottic drainage. At 6-month follow-up, neither quality of life, cognitive function, nor laryngeal injury differed between groups. However, the small number of survivors who provided information on their physical and mental status limits the conclusions that can be drawn regarding long-term outcome differences. FUNDING: National Institutes of Health and National Heart, Lung, and Blood Institute.