Daily Anesthesiology Research Analysis

BACKGROUND: Transesophageal echocardiography during out-of-hospital cardiac arrest can be performed during ongoing chest compressions and may improve resuscitation quality, but its prehospital use has not been systematically evaluated. To assess the feasibility, diagnostic yield, and impact of prehospital TEE on resuscitation metrics and advanced life support (ALS) interventions during OHCA. METHODS: We conducted a randomized controlled trial in a physician-staffed two-tiered emergency medical service (EMS). Adults with ongoing non-traumatic OHCA were randomized 1:1 to standard ALS or ALS plus TEE. The primary endpoints were hands-off time and chest compression fraction (CCF) from EMS arrival to return of spontaneous circulation (ROSC) or resuscitation termination. Secondary endpoints included ROSC at hospital admission, survival to hospital discharge, neurological status at hospital discharge, and TEE findings. Analyses followed the intention-to-treat principle. RESULTS: Of 249 screened patients, 35 were randomized and 32 analyzed (TEE n = 15; control n = 17). Median hands-off time was 4 s in both groups. Mean CCF was higher in the TEE group (96.2%) than the control group (91.6%), with a mean difference of 4.6% (95% confidence interval 2.5-6.7; p < 0.001). Sustained ROSC occurred in 40% (TEE) versus 71% (control; p = 0.083). The control group had an eCPR rate of 41%, compared to 20% in the TEE group. Using TEE, an incorrect area of maximal compression or inadequate depth was identified in 23% and 14%, respectively. CONCLUSION: Prehospital TEE during OHCA was feasible without negatively interfering with CPR metrics, and provided clinically relevant diagnostic information and procedural guidance, warranting further evaluation in larger trials. TRIAL REGISTRATION: German Clinical Trials Register DRKS00028695 registered on 28 April 2022.

OBJECTIVES: To assess whether systematic perioperative correction of anemia and/or iron deficiency (ID) improves hemoglobin (Hb) levels and reduces transfusion requirements in elective cardiac surgery. DESIGN: Post hoc analysis of a prospective, non-randomized, single-center before-and-after study with intention-to-treat analysis. The control phase was followed by the intervention phase. Adjustments were made using propensity-score overlap weighting and multiple imputation. SETTING: A tertiary academic hospital. PARTICIPANTS: Eight hundred thirty-four adults undergoing elective cardiopulmonary bypass surgery: 442 in the control phase and 392 in the subsequent intervention phase. INTERVENTIONS: The intervention group received systematic screening and treatment for anemia (Hb <13 g/dL) and/or ID (ferritin <100 µg/L or <300 µg/L with transferrin saturation <20%) using intravenous iron (1000 mg ferric carboxymaltose) and erythropoietin-α (600 IU/kg weekly, 1-3 doses). Postoperative IV iron (300 mg) was administered on days 0 and 2. The control group received standard care. MEASUREMENTS AND MAIN RESULTS: Hb significantly increased in anemic patients, with or without ID (+1.8 g/dL, p < 0.001). Patients with isolated ID also showed higher Hb at discharge and 3 months (p = 0.003). RBC transfusion rates were significantly reduced in anemic patients (with ID: 26.1% vs 55.9%, p = 0.003; without ID: 17.4% v 55.3%, p = 0.007). No differences in outcomes or mortality were observed. CONCLUSIONS: Systematic correction of anemia and/or ID significantly improves Hb levels and reduces transfusion needs in elective cardiopulmonary bypass surgery, supporting its role in perioperative patient blood management. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04040023): registered July 29, 2019.

BACKGROUND: Transfemoral transcatheter aortic valve implantation (TAVI) is a minimally invasive treatment for patients with severe aortic stenosis who are at elevated surgical risk. Despite widespread use, optimal periprocedural anaesthetic management remains highly variable, and evidence-based guidance is lacking. METHODS: An interdisciplinary panel of Italian experts in anaesthesiology, cardiology, and cardiac surgery conducted a systematic review of the literature and used the RAND/UCLA Appropriateness Method to evaluate 1032 clinical scenarios across a range of risk profiles and comorbid conditions. Ratings were conducted over three rounds, including a moderated in-person meeting to refine and discuss appropriateness scores. RESULTS: A minimally invasive approach, local anaesthesia alone, and conscious sedation were judged appropriate across most clinical scenarios. Invasive monitoring, such as placement of an additional arterial catheter or a central venous catheter, was recommended only in selected high-risk patients. Several approaches or interventions were consistently rated inappropriate across all evaluated scenarios, including nurse-administered anaesthesia, pulmonary artery catheterisation, and cardiac output monitoring using pulse wave analysis. Other approaches, such as general anaesthesia and deep sedation, were considered inappropriate in most cases but retained uncertainty in select clinical contexts. Several recommendations were rated as necessary to define a minimum standard of care. CONCLUSIONS: This Italian consensus statement provides practical, expert-driven recommendations to standardise anaesthetic care for transfemoral TAVI. While many recommendations reached strong consensus, areas of uncertainty remain, underscoring the need for further clinical research. Patient-centred, individualised decision-making remains essential, guided by institutional experience and procedural complexity.