Daily Anesthesiology Research Analysis
Analyzed 79 papers and selected 3 impactful papers.
Summary
An IPD meta-analysis of randomized trials shows high-flow nasal cannula (HFNC) markedly reduces desaturation and interruptions during bronchoscopy, with flows ≥45 L/min conferring added benefit. An ancillary analysis in cardiopulmonary bypass suggests organ injury is linked to impaired endotoxin inactivation rather than gut translocation, and intraoperative hemoadsorption did not lower endotoxin burden. A meta-analysis of RCTs supports adding adductor canal block to local infiltration analgesia to improve early pain and reduce PONV after total knee arthroplasty.
Research Themes
- Peri-procedural respiratory support optimization
- Inflammation and endotoxin biology in cardiac surgery
- Regional anesthesia strategies for joint arthroplasty
Selected Articles
1. High flow nasal cannula versus conventional oxygen therapy during bronchoscopy: A systematic review and individual participant data meta-analysis.
Across 17 RCTs (n=3,116), HFNC markedly reduced desaturation and procedure interruptions versus conventional oxygen during bronchoscopy, with an IPD analysis indicating stronger relative benefits at lower BMI and lower baseline respiratory/heart rates. Flows ≥45 L/min further reduced desaturation risk.
Impact: Provides high-level evidence with IPD on HFNC’s superiority during bronchoscopy and actionable parameters (flow ≥45 L/min) to optimize safety.
Clinical Implications: Adopt HFNC as first-line oxygenation for adult bronchoscopy, targeting flows ≥45 L/min when feasible, especially in patients with lower BMI and lower baseline respiratory/heart rates to minimize desaturation and interruptions.
Key Findings
- HFNC reduced desaturation versus COT during bronchoscopy (OR 0.23, 95% CI 0.15–0.34).
- HFNC decreased procedure interruption, escalation of respiratory support, and airway interventions.
- Flows ≥45 L/min were associated with additional reduction in desaturation risk (OR 0.28, 95% CI 0.12–0.65).
- IPD suggested greater relative benefit in patients with lower BMI and lower baseline respiratory/heart rates.
Methodological Strengths
- Systematic review of 17 RCTs with additional one-stage IPD meta-analysis
- Pre-registered protocol (PROSPERO) and clinically objective outcomes
Limitations
- IPD available from only 6 RCTs with potential selection bias
- Heterogeneity in HFNC settings and patient risk profiles; limited data in highest-risk cohorts
Future Directions: Prospective trials to define optimal HFNC flow/FiO2 titration across risk strata and to assess outcomes in high-risk patients (e.g., obesity, severe hypoxemia).
BACKGROUND: High-flow nasal cannula (HFNC) is superior to conventional oxygen therapy (COT) in preventing hypoxaemia during bronchoscopy. However, factors associated with HFNC effectiveness remain unclear. We performed an individual participant data meta-analysis (IPD-MA) to identify treatment modifiers for HFNC during bronchoscopy. METHODS: We systematically reviewed randomised controlled trials (RCTs) comparing HFNC and COT during bronchoscopy in adults (January 2000-September 2025) and requested IPD from corresponding investigators. The primary outcome was desaturation during bronchoscopy. Conventional meta-analysis was performed using random-effect model; one-stage regression model was used for IPD-MA. Results were reported as odds ratios (ORs) or mean difference and 95% confidence intervals (CIs). RESULTS: Seventeen RCTs (3,116 patients: 1680 HFNC, 1436 COT) were included. Compared to COT, HFNC significantly reduced desaturation (OR 0.23, 95% CI 0.15-0.34), procedure interruption (OR 0.36, 95% CI 0.20-0.67), respiratory support escalation (OR 0.25, 95% CI 0.11-0.55), and airway intervention (OR 0.19, 95% CI 0.10-0.36) during bronchoscopy. IPD was obtained from six RCTs (1,344 patients). Significant interactions were observed between treatment effect and body mass index, baseline respiratory and heart rates, with greater relative benefit at lower values. HFNC flows ≥45 L/min were associated with reduced desaturation risk (OR 0.28, 95% CI 0.12-0.65). CONCLUSIONS: HFNC is superior to COT in reducing desaturation and procedure-related interruptions during bronchoscopy. Exploratory analyses suggest greater relative benefits in patients with lower body mass index and lower baseline respiratory and heart rates. HFNC flows ≥45 L/min furtherreduce desaturation risk. Further studies are needed in higher-risk patients. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews; No.:CRD420251008924; URL: https://www.crd.york.ac.uk/prospero/.
2. Impaired endotoxin inactivation, rather than gut translocation, is associated with organ injury in cardiac surgery with cardiopulmonary bypass: An ancilliary analysis of a randomised control trial.
In prolonged CPB, endotoxin mass decreased but activity rose, and higher post-CPB endotoxin activity correlated with inotrope use, inflammation, and organ injury. Intraoperative hemoadsorption did not reduce endotoxin concentration or activity, implicating impaired inactivation rather than translocation as the key driver.
Impact: Shifts the focus of endotoxin-targeted strategies in cardiac surgery from removal to enhancing inactivation capacity; challenges the utility of hemoadsorption.
Clinical Implications: Routine hemoadsorption to reduce endotoxin burden during CPB is not supported. Monitoring endotoxin activity and exploring therapies that enhance endotoxin neutralization may better mitigate postoperative organ injury.
Key Findings
- After CPB, endotoxin mass decreased but activity increased relative to baseline.
- Higher postoperative endotoxin activity associated with intraoperative dobutamine use, elevated inflammatory biomarkers, and organ injury.
- Hemoadsorption did not reduce endotoxin plasma concentration or activity.
Methodological Strengths
- Serial measurement of endotoxin mass and activity at predefined perioperative time points
- Randomized parent trial framework with contemporaneous control arm
Limitations
- Single-center ancillary analysis with modest sample size (n=66)
- Not powered to detect clinical outcome differences; mechanistic inference observational
Future Directions: Evaluate biomarkers of endotoxin neutralization capacity and test targeted interventions (e.g., HDL mimetics, LBP/CD14-TLR4 pathway modulators) to enhance inactivation and improve outcomes after CPB.
BACKGROUNDS: In patients with cardiac surgery under cardiopulmonary bypass (CPB), postoperative inflammation is a driver of adverse outcomes. Endotoxaemia is one of the factors thought to trigger this inflammatory response. The mechanism behind high endotoxin activity (increased translocation vs. reduced inactivation capacity) has never been elucidated and may imply different therapeutic candidates. OBJECTIVES: We aimed to evaluate, in patients with cardiac surgery with prolonged CPB, mechanisms and consequences of endotoxaemia and the efficacy of haemo-adsorption to reduce the endotoxin burden. DESIGN: Ancillary analysis of a randomised controlled trial. Patients scheduled for cardiac surgery with prolonged CPB were assigned to receive either intra-operative haemo-adsorption or standard of care. Endotoxin mass and activity were measured before surgery, at the end of CPB, 6, 24 and 48 h after the end of surgery. SETTING: Operating room, Amiens University Hospital. PATIENTS: Adults scheduled for cardiac surgery under CPB with an expected CPB time more than 90 min. INTERVENTION: Patients were randomised to receive either haemo-adsorption or standard care during CPB. MAIN OUTCOME MEASURES: Endotoxin activity. RESULTS: Two hundred and ninety-five samples from 66 patients were analysed. Following CPB, we observed a reduction in endotoxin mass accompanied by a relative increase in endotoxin activity. High postoperative endotoxin activity was associated with intra-operative dobutamine requirement, increased postoperative inflammatory biomarkers and organ injury. Endotoxin plasma concentration and activity were not lower in patients treated with haemo-adsoprtion. CONCLUSION: The capacity of individuals to inactivate endotoxin rather than raw endotoxin mass (i.e. Quantity) seemed to be a determinant of endotoxin noxious effect in cardiac surgery and CBP. Haemo-adsorption was not associated with a reduction of endotoxin plasma mass or activity in patients with cardiac surgery under CPB. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04201119NCT04201119.
3. Comparative Efficacy of Adductor Canal Block in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
Across 26 RCTs (n=2,400), adding ACB to LIA improved pain at rest and during activity at 24–48 hours, reduced opioid use, and modestly improved early ROM. ACB alone reduced activity-related pain versus LIA but not pain at rest; PONV was lower with ACB.
Impact: Synthesizes randomized evidence supporting motor-sparing regional anesthesia (ACB) as an effective adjunct to LIA for early analgesia after TKA.
Clinical Implications: Consider routine addition of ACB to LIA in TKA to improve early pain control and reduce PONV, while recognizing heterogeneity and variable certainty of evidence.
Key Findings
- ACB+LIA lowered pain scores at 24 and 48 hours at rest and during activity versus LIA alone.
- ACB+LIA reduced opioid consumption and improved 24-hour knee ROM.
- ACB alone reduced activity-related pain versus LIA but not pain at rest; PONV was lower with ACB.
- Evidence certainty ranged from moderate to very low with moderate-to-high risk of bias.
Methodological Strengths
- Restriction to randomized controlled trials with random-effects modeling
- Prespecified primary and secondary outcomes with RoB-2 and GRADE assessments
Limitations
- Heterogeneity in ACB techniques, dosing, and LIA protocols
- Moderate-to-high risk of bias and variable certainty; limited long-term outcomes
Future Directions: Head-to-head trials standardizing ACB/LIA protocols, assessing functional recovery and long-term outcomes, and optimizing multimodal regimens.
BACKGROUND: Peripheral nerve blocks are an integral part of the multimodal analgesia for total knee arthroplasty (TKA). The adductor canal block (ACB) gained popularity for its motor-sparing effect. This study evaluated ACB alone or combined with local infiltration analgesia (LIA), in comparison to LIA alone in TKA patients. METHODS: A systematic review and meta-analysis of randomized controlled trials (RCTs) was performed. The MEDLINE and PMC using PubMed, Cochrane Library, and Scopus databases were searched for RCTs evaluating ACB alone or with LIA compared to LIA alone after TKA published up to December 18, 2024. The random-effect model was used for both the standardized mean difference (SMD) of continuous parameters, as well as for the odds ratio of binary parameters. Postoperative pain scores assessed by a visual analog scale or a numerical rating scale at 24 and 48 hours constituted the primary outcome. Secondary outcomes were opioid consumption, knee range of motion (ROM), length of hospital stay, and postoperative nausea and vomiting (PONV). The risk of bias was assessed with the risk of bias tool 2 (RoB-2). RESULTS: In total, 26 studies (2,400 patients) were included. Static and dynamic pain scores at 24 and 48 hours in the ACB+LIA group compared to LIA alone were lower (SMD24rest = -0.54, 95% confidence interval [CI], -0.80 to -0.28, P < .00001; SMD24activity = -0.85, 95% CI, -1.37 to -0.32, P = .001; SMD48rest= -0.26, 95% CI, -0.49 to -0.03, P = .02; SMD48activity = -0.66, 95% CI, -0.96 to -0.36, P ≤ .0001). ACB alone reduced pain during activity but not at rest compared to LIA (SMD24activity = -0.93, 95% CI, -1.88 to 0.02, P = .05; SMD48activity = -1.10, 95% CI, -2.03 to -0.17 P = .02). Reduced opioid consumption (P = .005) and greater ROM at 24 hours (P = .02) were observed with ACB+LIA. Regarding the remaining outcomes, no differences were observed in opioid consumption, ROM, and hospital stay. ACB patients experienced lower PONV rates (P = .05). The GRADE framework rated evidence certainty from moderate to very low with a moderate to high bias according to the RoB-2. CONCLUSION: Adding ACB to LIA improves pain scores at 24 and 48 hours compared to LIA alone.