Daily Anesthesiology Research Analysis

IMPORTANCE: The effect of individualized high positive end-expiratory pressure (PEEP) and recruitment maneuvers, targeting a low driving pressure, on clinical outcomes in patients undergoing open abdominal surgery is uncertain. OBJECTIVE: To compare driving pressure-guided high PEEP and recruitment maneuvers with standard low PEEP without recruitment maneuvers with respect to postoperative pulmonary complications. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial of 1435 adults at increased risk for postoperative pulmonary complications who were scheduled for open abdominal surgery. The trial was conducted at 29 sites in 5 countries across Europe from April 2019 to December 2024; final follow-up was in March 2025. Statistical analysis was conducted in May 2025. INTERVENTION: Patients were randomized to undergo intraoperative ventilation with driving pressure-guided high PEEP and recruitment maneuvers (n = 718) or to intraoperative ventilation with standard low PEEP (n = 717). All patients received low tidal volume ventilation. MAIN OUTCOMES AND MEASURES: The primary outcome was a composite of pulmonary complications within the first 5 postoperative days, including severe respiratory failure, bronchospasm, suspected pulmonary infection, pulmonary infiltrates, aspiration pneumonitis, atelectasis, acute respiratory distress syndrome, pleural effusion, cardiopulmonary edema, and pneumothorax. Among the 16 prespecified secondary outcomes, 4 concerned intraoperative complications, including hypotension (decrease in mean arterial pressure of >20% for >3 minutes) and desaturation (Spo2 <92% for >1 minute). RESULTS: Among 1468 adults, 1435 (98%) completed the trial (median [IQR] age, 66 [57-74] years; 52% female). In the primary analysis population, the primary outcome occurred in 142 of 718 patients (19.8%) in the driving pressure-guided high PEEP group compared with 125 of 717 patients (17.4%) in the low PEEP group (absolute difference, 2.5% [95% CI, -1.5% to 6.4%]; P = .23). The incidence of hypotension (382 [54.0%] vs 317 [45.0%]) and use of vasoactive agents (224 [32.0%] vs 130 [18.8%]) was higher in the high PEEP group; the incidence of intraoperative desaturation (6 [0.8%] vs 20 [2.8%]) was higher in the low PEEP group. CONCLUSIONS AND RELEVANCE: Among patients at increased risk for postoperative pulmonary complications undergoing open abdominal surgery under general anesthesia, intraoperative ventilation with driving pressure-guided high PEEP and recruitment maneuvers, compared with a strategy with standard low PEEP, did not reduce postoperative pulmonary complications. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03884543.

IMPORTANCE: Explanatory trials suggest that prehabilitation has efficacy in improving surgical outcomes. The effectiveness of offering home-based prehabilitation across multiple centers and for older adults with frailty remains unknown. OBJECTIVE: To evaluate the effectiveness of offering coach-supported, home-based prehabilitation to older surgical patients with frailty. DESIGN, SETTING, AND PARTICIPANTS: This study is a pragmatic, parallel-arm, multicenter randomized clinical trial with embedded qualitative assessment. Clinicians and assessors were fully blinded; participants were partially blinded in that the control arm received publicly available activity and nutritional guidelines. From March 2, 2020, to February 8, 2024, participants aged 60 years and older with frailty (Clinical Frailty Scale score ≥4) scheduled for elective, inpatient noncardiac surgery were recruited from surgeon's offices at 13 centers in Canada. Data analysis was completed from October 3, 2024, to December 5, 2024. INTERVENTION: Assignment to a home-based, multimodal program of exercise and personalized nutritional recommendations, remotely supported by coaches using a theory-based approach to enhance adherence. MAIN OUTCOMES AND MEASURES: The coprimary outcomes were patient-reported disability 30 days after surgery using the World Health Organization Disability Assessment Schedule 2.0 and the incidence of any postoperative complication during the surgical hospitalization. Barriers to adherence were identified using the Theoretical Domains Framework. Secondary outcomes were intervention-attributable safety events, health-related quality of life, survival, falls, complication severity, activities of daily living, length of stay, discharge disposition, lower limb function, and readmission. Analysis was by mixed-effects regression, adjusting for stratification and prespecified prognostic factors. RESULTS: Of 992 eligible participants, 847 (85.4%) were randomized (423 to prehabilitation and 424 to usual care), and 705 participants had their planned surgery (353 in the prehabilitation group and 352 in the usual care group). A total of 452 participants (53.4%) were female, and mean (SD) participant age was 71.7 (7.1) years. A median (IQR) of 4 weeks (3-7) of prehabilitation enrollment was achieved. Preoperative safety outcomes did not differ between groups. Participants assigned to prehabilitation reported a mean (SD) postoperative disability score of 23.5 (21.8) compared to 24.7 (23.8) for usual care (adjusted mean difference, -1.4; 97.5% CI, -4.9 to 2.0; P = .36). Complications occurred in 177 participants (50.1%) assigned to prehabilitation and 168 control participants (47.7%) (adjusted odds ratio, 1.05; 97.5% CI, 0.73-1.49; P = .78). Participants completing more than 75% of prescribed exercises reported significantly lower disability scores with prehabilitation (mean difference, -4.9; 97.5% CI, -9.8 to -0.01; P = .02), but there was no significant difference in complications (odds ratio, 1.06; 97.5% CI, 0.67-1.67; P = .79). Primary barriers to adherence were competing priorities and motivation. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial among older adults with frailty scheduled for surgery, assignment to home-based prehabilitation before surgery did not improve postoperative disability scores or reduce complications. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04221295.

BACKGROUND: Central venous catheterization is the most common invasive procedure in intensive care units but remains burdened by infectious, thrombotic, and mechanical complications. Although real-time ultrasound guidance is now widely adopted, its effect on site-specific differences in overall complication rates has not been established. The 3SITES randomized clinical trial previously demonstrated lower infection and thrombosis rates with subclavian access but higher mechanical complications. However, as only a third of its procedures were ultrasound-guided in this study, these findings may not apply to current practice. The objective of the study was to compare complication rates across these three sites under a counterfactual framework assuming universal ultrasound guidance. METHODS: This study was an emulated a target trial using the 3SITES dataset. Inverse probability weighting was applied to adjust for confounders of site assignment and ultrasound guidance. Weighted outcomes across catheter sites were compared under a counterfactual framework assuming universal ultrasound guidance. The primary outcome was a composite of time to catheter-related bloodstream infection or symptomatic deep-vein thrombosis. Secondary outcomes included each component separately, asymptomatic thrombosis, and major mechanical complications. RESULTS: A total of 3409 catheters were included: 1153 in the femoral, 1267 in the internal jugular, and 989 in the subclavian site. Subclavian site showed a lower incidence of the primary outcome compared with femoral (P = .02) and jugular (P = .001) sites. The primary composite outcome did not differ between internal jugular and femoral sites (P = .97). Catheter-related bloodstream infections were significantly fewer with subclavian versus jugular access (P = .001). Asymptomatic thrombosis was more frequent at femoral and jugular sites. Major mechanical complications were rare and did not differ significantly across sites. CONCLUSION: Assuming universal real-time ultrasound-guided central venous catheterization, subclavian access retains lower infectious and thrombotic risk without an observed increase in mechanical complications, supporting its preferential use in intensive care units.