Daily Anesthesiology Research Analysis
Three high-impact studies advance perioperative and critical care anesthesiology. A nationwide ICU cohort shows rising mortality and withdrawal of life-sustaining therapy in traumatic brain injury, prompting ethical and quality-of-care scrutiny. A comprehensive meta-analysis confirms transversus abdominis plane blocks reduce postoperative pain and opioid use, while a 15-year observational study links higher rocuronium dosing post-sugammadex to dose-dependent respiratory complications mitigated b
Summary
Three high-impact studies advance perioperative and critical care anesthesiology. A nationwide ICU cohort shows rising mortality and withdrawal of life-sustaining therapy in traumatic brain injury, prompting ethical and quality-of-care scrutiny. A comprehensive meta-analysis confirms transversus abdominis plane blocks reduce postoperative pain and opioid use, while a 15-year observational study links higher rocuronium dosing post-sugammadex to dose-dependent respiratory complications mitigated by quantitative neuromuscular monitoring.
Research Themes
- Ethics and outcomes in neurocritical care (TBI mortality and WLST trends)
- Opioid-sparing regional anesthesia strategies (TAP block effectiveness)
- Neuromuscular blockade safety and monitoring in modern anesthesia
Selected Articles
1. Hospital mortality, withdrawal of life-sustaining therapy decisions and early secondary brain insults for critically ill traumatic brain injury patients in England, Wales and Northern Ireland (2009-2024): an observational cohort study.
In a 15-year, 235-ICU cohort of 45,684 TBI patients, hospital mortality rose from 25.6% to 35.0% and WLST decisions from 7.5% to 19.7%, trends not seen in comparator cohorts. Exposure to early secondary brain insults, notably hypoxemia, increased substantially. Findings urge re-examination of WLST processes, neuroprotective care quality, and system factors influencing decisions.
Impact: This is a large, contemporary, multicenter dataset revealing concerning trends unique to TBI, linking outcomes to early secondary insults and WLST decisions, with direct implications for neurocritical care quality and ethics.
Clinical Implications: Prioritize prevention of secondary brain insults (e.g., hypoxemia) through protocolized neuroprotective bundles and continuous monitoring. Establish transparent, multidisciplinary WLST frameworks with structured prognostication and bias mitigation.
Key Findings
- Hospital mortality in ICU TBI patients increased from 25.6% to 35.0% (2009–2024).
- WLST decisions increased from 7.5% to 19.7%, independent after adjustment.
- No similar increases were observed in trauma, sepsis, or vascular brain injury comparator cohorts.
- Exposure to hypoxemia rose from 36.9% to 61.2%; hypotension, (hypo/hyper)capnia, and hyperglycemia were common.
Methodological Strengths
- Nationwide, multicenter cohort (235 ICUs) over 15 years with comparator cohorts
- Adjusted multivariable analyses and predefined secondary brain insult metrics
Limitations
- Observational design limits causal inference regarding WLST and mortality
- Potential secular changes in case mix, practice patterns, and documentation
Future Directions: Prospective studies to disentangle prognostication accuracy, decision-making processes, and modifiable care pathways; quality initiatives targeting hypoxemia and physiologic derangements.
BACKGROUND: Recent epidemiological studies reported conflicting results regarding mortality trends for traumatic brain injury (TBI) patients. Mortality trends for the critically ill TBI population, and their drivers of changes, remains understudied. Particularly, withdrawal of life-sustaining therapy (WLST) decisions were rarely evaluated concurrently. In this study, we aimed to describe hospital mortality and WLST trends over the past 15 years in England, Wales and Northern Ireland for TBI patients admitted to an intensive care unit (ICU). METHODS: Observational cohort study, involving 235 adult ICUs participating in the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme (CMP). From April 1, 2009 to March 31, 2024, all TBI patients were included. Comparator cohorts consisted of patients with trauma, sepsis, and vascular brain injury recorded in the CMP. The primary outcome was hospital mortality. The secondary outcome was the incidence of WLST decisions. We also examined the proportion of patients experiencing predefined early secondary brain insults. FINDINGS: Of the 2,324,961 ICU admissions, we identified 45,684 unique TBI patients. Over the study period, hospital mortality for TBI patients increased from 25.6% (1021/3988) to 35.0% (1306/3727). The proportion of WLST decisions rose from 7.5% (301/4024) to 19.7% (759/3850). After adjustment for main confounders, multivariable analyses confirmed these trends. No similar trends were observed among the comparator cohorts. TBI patients were exposed to hypotension, hypocapnia, hypercapnia and hyperglycaemia in 49.8% (22,559/45,298), 29.9% (12,356/41,262), 33.6% (13,869/41,262) and 29.2% (12,127/41,505) of cases, respectively. Half of patients (50.3%, 20,747/41,265) were exposed to hypoxaemia, and this proportion increased markedly from 36.9% (1359/3684) to 61.2% (2186/3572) over time. INTERPRETATION: For critically ill TBI patients, hospital mortality and WLST decisions rates increased over time. These findings raise important questions regarding the processes and ethical frameworks underpinning WLST decisions. FUNDING: UKRI, NIHR, UK Ministry of Defence, Alzheimer's Research UK, French Society of Anaesthesiology and Critical Care, Gueules Cassées Foundation, INNOVEO donation fund.
2. Transversus abdominis plane block for postoperative pain management and opioid sparing: a systematic review and meta-analysis of randomised controlled trials.
Across 123 RCTs, TAP blocks significantly reduced early postoperative pain scores and 24-hour morphine consumption versus placebo and local infiltration. Compared with epidural analgesia, benefits were limited (12-hour pain only), and TAP performed similarly to intrathecal morphine. Findings support TAP block as an effective, opioid-sparing component of multimodal analgesia after abdominal surgery.
Impact: Provides high-level, up-to-date evidence across surgeries confirming analgesic and opioid-sparing benefits of TAP blocks and clarifies comparisons with epidural and intrathecal morphine.
Clinical Implications: Incorporate TAP blocks into standardized multimodal analgesia pathways for abdominal procedures, particularly when epidural is contraindicated or resource-intensive; tailor expectations versus epidural or intrathecal morphine.
Key Findings
- TAP block reduced 6-, 12-, and 24-hour pain scores versus local infiltration (e.g., SMD −0.89 at 6 h; −1.27 at 12 h; −0.66 at 24 h).
- TAP block lowered cumulative 24-hour morphine consumption versus local infiltration (SMD −0.99).
- Benefits versus epidural analgesia were limited to 12-hour pain scores; no significant differences versus intrathecal morphine.
Methodological Strengths
- Comprehensive search and meta-analysis across 123 RCTs with prespecified outcomes
- Protocol registered (PROSPERO), multiple active comparators analyzed
Limitations
- Heterogeneity in techniques, local anesthetic dosing, and surgical populations
- Limited data for certain comparators/time points; potential publication bias
Future Directions: Head-to-head trials versus optimized epidurals and intrathecal morphine in defined procedures; dose–response and adjuvant studies; cost-effectiveness and ERAS integration analyses.
BACKGROUND: The transversus abdominis plane (TAP) block is a regional anaesthetic technique targeting thoracolumbar sensory nerve afferents to provide analgesia to the anterolateral abdominal wall. With emerging RCTs supporting its efficacy across various surgeries, an updated, comprehensive review is warranted to assess its analgesic effectiveness and opioid sparing potential. METHODS: A systematic review and meta-analysis were conducted to assess the analgesic efficacy of the TAP block. We searched MEDLINE, Embase, and Cochrane CENTRAL from inception to May 2024. We included RCTs that compared the TAP block with placebo, local infiltration, epidural analgesia, or intrathecal morphine and reported 6-, 12-, or 24-h postoperative pain scores or cumulative 24-h postoperative morphine consumption. Meta-analyses were performed for all outcomes. RESULTS: A total of 123 RCTs were included in this review. The TAP block group showed significant reductions across all outcomes when compared with placebo. When compared with local infiltration, the TAP block also showed significant reductions in 6-h (standardised mean difference [SMD]=-0.89; 95% confidence interval [95% CI], -1.35 to -0.43; P<0.001), 12-h (SMD=-1.27; 95% CI, -2.08 to -0.46; P=0.002), and 24-h (SMD=-0.66; 95% CI, -1.01 to -0.32; P<0.001) postoperative pain, and in cumulative 24-h postoperative morphine consumption (SMD=-0.99; 95% CI, -1.52 to -0.47; P<0.001). However, it only showed a reduction in 12-h pain scores when compared with epidural analgesia and did not differ significantly with intrathecal morphine for any of the outcomes. CONCLUSIONS: The TAP block is an effective anaesthetic modality for pain management and opioid sparing after abdominal surgery. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42024374067).
3. Changes in intraoperative rocuronium dosing following the introduction of sugammadex and association with postoperative respiratory complications: A retrospective cohort study.
After sugammadex introduction, cumulative intraoperative rocuronium dosing increased from 0.83 to 1.20 mg/kg (≈45%). Respiratory complications rose dose-dependently, but the risk was attenuated with sugammadex and abolished when quantitative neuromuscular monitoring (train-of-four ratio) was used, unlike qualitative monitoring.
Impact: Defines real-world unintended consequences of sugammadex-enabled deep blockade and highlights quantitative monitoring as a safety-critical countermeasure.
Clinical Implications: Adopt routine quantitative neuromuscular monitoring to prevent residual blockade-related respiratory complications, especially when using higher cumulative rocuronium dosing enabled by sugammadex.
Key Findings
- Rocuronium dosing increased by 0.05 mg/kg per year after September 2016 (0.83 to 1.20 mg/kg by 2024).
- 8.4% experienced postoperative respiratory complications; risk increased per 1 mg/kg additional rocuronium.
- Dose–risk association was strongest without sugammadex or neuromuscular monitoring (ORadj 1.99).
- Risk attenuated with sugammadex (ORadj 1.08) and was abolished with quantitative monitoring (ORadj 0.94), but not with qualitative monitoring.
Methodological Strengths
- Very large single-center cohort with interrupted time-series analysis and covariate adjustment
- Effect modification evaluated by reversal strategy and monitoring modality
Limitations
- Single-center retrospective design; residual confounding and practice pattern bias possible
- No direct causality; outcomes limited to early postoperative respiratory events
Future Directions: Prospective, multicenter studies testing dosing strategies aligned with quantitative monitoring thresholds; implementation science on universal quantitative monitoring and NMBA stewardship.
BACKGROUND: Neuromuscular blocking agents dose-dependently precipitate residual neuromuscular blockade and postoperative respiratory complications. The introduction of sugammadex allowed for reversal of even deep neuromuscular blockade and might have provoked more liberal use of neuromuscular blocking agents. We investigated whether the introduction of sugammadex led to higher intraoperative rocuronium doses and whether this impacted postoperative respiratory complications. METHODS: 163,402 adult patient cases who underwent general anesthesia and received exclusively rocuronium at an academic medical center between 2010 and 2024 were included. Interrupted-time-series-analysis adjusted for patient and procedural characteristics was applied to assess changes in cumulative intraoperative rocuronium doses (mg/kg body-weight) following sugammadex introduction in September 2016. Rocuronium-associated risks of postoperative respiratory complications (post-extubation desaturation<90%, 7-day reintubation or emergency non-invasive ventilation) and effect modification by use of sugammadex and qualitative (twitch-count) versus quantitative (train-of-four-ratio) neuromuscular monitoring were evaluated. Reported odds ratios represent the dose-response association (per 1mg/kg rocuronium increase) within the respective subgroup of patient cases. RESULTS: Following a stable baseline (-0.01mg/kg per year between January 2010 and August 2016;95%CI -0.05-0.03mg/kg;p=0.58), rocuronium doses increased by 0.05mg/kg annually after introduction of sugammadex (95%CI 0.03-0.07mg/kg;p<0.001) from 0.83mg/kg (SD±0.49mg/kg) in August 2016 to 1.20mg/kg (SD±0.65mg/kg) in January 2024. 9,101 out of 108,317 patient cases (8.4%) experienced postoperative respiratory complications. Rocuronium was dose-dependently associated with higher postoperative respiratory complications risks, which was most pronounced among patient cases receiving neither sugammadex nor neuromuscular monitoring (ORadj1.99 per 1mg/kg;95%CI 1.82-2.18;p<0.001). This association was attenuated when sugammadex was administered (n=42,141;median dose 200mg; interquartile-range 200-300mg;ORadj1.08 per 1mg/kg;95%CI 1.01-1.16;p=0.023;p-for-interaction<0.001) and abolished with quantitative (n=25,564;ORadj0.94 per 1mg/kg;95%CI 0.85-1.03;p=0.19;p-for-interaction<0.001) but not qualitative neuromuscular monitoring (n=49,045;ORadj1.10 per 1mg/kg;95%CI 1.02-1.18;p=0.017;p-for-interaction<0.001). CONCLUSIONS: Sugammadex introduction was followed by a 45.1% increase in rocuronium doses. While sugammadex attenuated the risk of postoperative respiratory complications, it was only completely abolished with quantitative neuromuscular monitoring.