Daily Anesthesiology Research Analysis
Three high-impact perioperative studies stand out today: a large multicenter JAMA RCT shows that intraoperative driving pressure–guided high PEEP with recruitment maneuvers does not reduce postoperative pulmonary complications compared with standard low PEEP; a pragmatic multicenter RCT in JAMA Surgery finds no overall benefit of home-based prehabilitation for frail older adults ahead of noncardiac surgery; and a target trial emulation in Critical Care supports preferring subclavian over jugular
Summary
Three high-impact perioperative studies stand out today: a large multicenter JAMA RCT shows that intraoperative driving pressure–guided high PEEP with recruitment maneuvers does not reduce postoperative pulmonary complications compared with standard low PEEP; a pragmatic multicenter RCT in JAMA Surgery finds no overall benefit of home-based prehabilitation for frail older adults ahead of noncardiac surgery; and a target trial emulation in Critical Care supports preferring subclavian over jugular/femoral sites for central venous catheters under universal ultrasound guidance without added mechanical harm.
Research Themes
- Intraoperative ventilation strategies and postoperative pulmonary complications
- Effectiveness of prehabilitation in frail older surgical patients
- Ultrasound-guided central venous access site selection and complications
Selected Articles
1. Intraoperative Driving Pressure-Guided High PEEP vs Standard Low PEEP for Postoperative Pulmonary Complications.
In adults at risk undergoing open abdominal surgery, a driving pressure–guided high PEEP strategy with recruitment maneuvers did not reduce postoperative pulmonary complications versus standard low PEEP. The high PEEP strategy increased intraoperative hypotension and vasoactive use, while low PEEP had more brief desaturation events. All patients received low tidal volume ventilation.
Impact: This definitive multicenter RCT provides high-quality negative evidence against routine use of driving pressure–guided high PEEP with recruitment maneuvers to prevent pulmonary complications, clarifying a debated intraoperative strategy.
Clinical Implications: Avoid routine high PEEP with recruitment maneuvers to prevent postoperative pulmonary complications in open abdominal surgery; prioritize low tidal volumes and consider hemodynamic tolerance. Tailored PEEP strategies should be reserved for selected physiologic indications.
Key Findings
- Primary composite pulmonary complications: 19.8% (high PEEP) vs 17.4% (low PEEP); absolute difference 2.5% (95% CI −1.5% to 6.4%), P=0.23
- Higher intraoperative hypotension and vasoactive use with high PEEP; more desaturation events in the low PEEP group
- All patients received low tidal volume ventilation; 29 sites across 5 European countries; n=1435 completed
Methodological Strengths
- Large, multicenter randomized clinical trial with high completion rate
- Standardized low tidal volume ventilation and prespecified outcomes
Limitations
- Composite primary outcome may dilute specific effect signals
- Potential lack of blinding to intraoperative strategy; generalizability primarily to open abdominal surgery
Future Directions: Identify physiologic subgroups that may benefit from higher PEEP or recruitment, refine driving pressure targets, and evaluate hemodynamic-optimized ventilation protocols.
2. Home-Based Prehabilitation for Older Surgical Patients With Frailty: A Randomized Clinical Trial.
Coach-supported, home-based prehabilitation for frail older adults did not reduce 30-day disability or in-hospital complications versus usual care. Patients achieving >75% exercise adherence had lower disability but without fewer complications; adherence barriers included competing priorities and motivation.
Impact: As a pragmatic multicenter RCT during routine care, this study challenges assumptions of universal prehabilitation benefit in frail older adults and redirects focus toward adherence and patient selection.
Clinical Implications: Do not assume routine benefit from home-based prehabilitation in frail older adults; invest in strategies that enhance adherence and target patients most likely to benefit. Consider integrating behavioral support and monitoring to improve uptake.
Key Findings
- No significant difference in 30-day disability (adjusted mean difference −1.4; 97.5% CI −4.9 to 2.0; P=0.36)
- No reduction in in-hospital complications (adjusted OR 1.05; 97.5% CI 0.73–1.49; P=0.78)
- Exercise adherence >75% associated with lower disability (mean difference −4.9) but no difference in complications
Methodological Strengths
- Pragmatic multicenter randomized design with blinded clinicians/assessors
- Prespecified coprimary outcomes and adjusted mixed-effects analyses
Limitations
- Partial blinding of participants; heterogeneous surgical population
- Adherence variability likely diluted effect; COVID-19 era logistics may have influenced engagement
Future Directions: Develop adherence-optimized, targeted prehabilitation with behavioral support, remote monitoring, and adaptive dosing; test in enriched populations with physiologic deficits and clear functional endpoints.
3. Site-specific complications of central venous catheterization under systematic ultrasound guidance: a target trial emulation revisiting the 3SITES study.
In a target trial emulation assuming universal ultrasound guidance, subclavian CVCs had fewer catheter-related bloodstream infections and symptomatic DVTs versus jugular and femoral, with no significant increase in major mechanical complications. These results support preferring subclavian access in modern ultrasound-guided practice.
Impact: By updating landmark RCT findings to current ultrasound-guided practice using causal inference, this study offers actionable guidance to minimize infectious/thrombotic risk without added mechanical harm.
Clinical Implications: When feasible, prefer subclavian site under real-time ultrasound with strict sterile technique and trained operators to reduce CRBSI and DVT risks without increasing major mechanical complications.
Key Findings
- Primary composite (CRBSI or symptomatic DVT) lower with subclavian vs femoral (P=.02) and vs jugular (P=.001)
- CRBSI significantly fewer with subclavian vs jugular (P=.001); asymptomatic thrombosis more frequent at femoral and jugular sites
- Major mechanical complications were rare and did not differ significantly across sites; n=3409 catheters
Methodological Strengths
- Target trial emulation with inverse probability weighting to address confounding
- Large sample across three sites with clinically relevant outcomes
Limitations
- Observational emulation subject to residual confounding and modeling assumptions
- Original dataset had limited ultrasound use; counterfactual extrapolation may not capture all nuances
Future Directions: Prospective comparative studies under mandatory ultrasound guidance; operator training standards and bundle approaches to further reduce CVC complications.