Daily Anesthesiology Research Analysis

BACKGROUND: Surgical resection is a widely used treatment for cancer. Patients can be "seeded" with their own cancer cells during surgery, and it has been postulated that the immune response to these circulating cancer cells can influence recurrence risk. Some preclinical and retrospective studies have suggested that propofol-based general anesthesia may be superior to volatile halogenated ethers with respect to cell-mediated immunity, implantation of circulating tumor cells, and cancer-related outcomes, but there are limited data from large randomized clinical trials. METHODS: The General Anesthetics in Cancer Resection (GA-CARES) trial is a multicenter, pragmatic, investigator-initiated, partially blinded, randomized superiority trial. Adults at five U.S. centers undergoing surgical resection of cancers associated with poor outcomes (pancreas, esophagus, lung, stomach, bile ducts, liver, bladder, or peritoneal surface) were randomized (1:1) to receive exclusive use of either propofol or volatile agent for maintenance of general anesthesia. The intent-to-treat population included all randomized patients (n = 1,766) minus 3 patients who withdrew consent before surgery. The per-protocol population included patients completing surgery, with pathologically confirmed cancer, and receiving the assigned anesthetic drug. The primary endpoint was all-cause mortality (minimum 2-yr follow-up). Secondary endpoints included disease-free survival. RESULTS: Adherence to the protocol was high, with 95.9% of patients who had surgery receiving the assigned anesthetic exclusively. In contrast to the authors' hypothesis, propofol-treated patients did not exhibit better survival (propofol 230 deaths out of 881 [26.1%] vs. volatile 202 deaths out of 882 [22.9%]; hazard ratio, 1.16; 95% CI, 0.96 to 1.41; P = 0.115 by exact stratified log rank test) in the intent-to-treat population (n = 1,763). In the per-protocol population (n = 1,411), significantly more patients randomized to propofol died through 2-yr follow-up (25.5% vs. 20%; hazard ratio, 1.31; 95% CI, 1.05 to 1.64; P = 0.017). Results were similar for disease-free survival (hazard ratio, 1.10; 95% CI, 0.9 to 1.36; P = 0.428) and were consistent across numerous subgroups. CONCLUSIONS: Propofol-based anesthesia is not effective at improving cancer-related outcomes in patients undergoing resection of malignancies.

OBJECTIVE: To develop, apply, and validate a system for evaluating critical care guideline adherence, and to identify factors influencing real-world adherence across hospitals. DESIGN: Retrospective, multicenter observational study evaluating guideline adherence over 3.5 years and comparing automated adherence monitoring against expert human review. SETTING: Five university hospitals with different clinical information systems and data infrastructures. PATIENTS: A total of 82,000 intensive care episodes (2.2 million patient days). Six representative recommendations were selected from 41 intensive care guidelines and translated into a standardized digital format. Expert review encompassed more than 18,000 patient days. INTERVENTIONS: An automated system that applies digitally encoded guideline recommendations to standardized patient data extracted from hospital information systems. MEASUREMENTS AND MAIN RESULTS: The system determined, for each patient and recommendation, whether the recommendation applied (applicability) and whether treatment followed it (adherence). The primary outcome was the system's accuracy in identifying guideline applicability and adherence compared with manual clinician reviews. The secondary outcome was an analysis of how adherence to these recommendations varied and which factors influenced their real-world implementation. The system achieved 97.0% accuracy in identifying guideline applicability and adherence, significantly outperforming human reviewers (86.6% accuracy, p < 0.001; McNemar's test). The processing speed of the system exceeded 2000 patient days per second, compared with manual review at 2 patient days per minute. Adherence rates varied substantially across participating sites and over time, reflecting documentation inconsistencies, evolving clinical knowledge, and challenges in maintaining strict compliance. CONCLUSIONS: The guideline adherence monitoring system was successfully applied in multiple hospitals, demonstrating higher accuracy and efficiency compared with human review. Limitations of the system included dependence on consistent and structured documentation, as inconsistencies significantly complicate adherence monitoring. As the system is designed to support any guideline in the digital format used here, it provides a scalable solution for automated quality management in critical care.

BACKGROUND: The prevalence of people with Diabetes Mellitus (DM) presenting for surgery is increasing. Guidelines on perioperative management are based on expert opinion with variability of practice likely. Our objective was to document perioperative management and 30-day outcomes of people with DM across Europe. METHODS: This was a prospective, observational study involving 89 hospitals across 21 European countries, ranging from district general to tertiary referral centres. Between January 2021 and February 2024, 6126 people with confirmed DM (any type except gestational) receiving surgery of any kind requiring anaesthesia were followed for 30 days. Centres were self-selected by anaesthesiology clinicians working there, who enrolled consecutive people with DM to a locally determined target number. There was 5936 (97%) 30-day follow-up completion. The primary outcome was Days at Home at 30 Days (DAH-30). Secondary outcomes included descriptive characteristics of perioperative management, dysglycaemia and incidence of postoperative complications. FINDINGS: There was significant variation between countries in perioperative DM management and 30-day outcomes, and variance in DAH-30 (median [range]) 26 [23-30] days, P = 0.0001). The proportion of people with DM with increased HbA1c (>69 mmol mol) was higher in T1DM compared with T2DM (n = 51, 18% vs n = 388, 7%; difference 11%, 95% CI 6-17; P = 0.002). In univariate analysis, there was an association between patients with lower HbA1c < 53 mmol mol INTERPRETATION: There is a need to harmonise international practice to reduce variability in perioperative diabetes management and 30-day outcome. FUNDING: The European Society of Anaesthesiology and Intensive Care (ESA-IC) funded administrative staff throughout the conduct of the study. The College of Anaesthesiologists of Ireland (CAI) and British Journal of Anaesthesia (BJA) partially contributed to data collection in Ireland and UK.