Daily Anesthesiology Research Analysis
Analyzed 88 papers and selected 3 impactful papers.
Summary
Top advances span perioperative electrolyte management, vascular-targeted sepsis biology, and hemodynamic drivers of postoperative brain dysfunction. A double-blind RCT shows nebulized salbutamol outperforms glucose–insulin for preventing reperfusion hyperkalemia in liver transplantation. Mechanistic work identifies truncated procalcitonin as a modifiable driver of endothelial injury in sepsis, and a meta-analysis links intraoperative hypotension to higher postoperative delirium risk.
Research Themes
- Perioperative electrolyte and organ protection strategies in transplantation
- Endothelial-targeted mechanisms and therapeutics in sepsis
- Intraoperative hemodynamics and postoperative delirium risk
Selected Articles
1. Comparison of nebulized salbutamol and glucose-insulin for preventing acute hyperkalemia in liver transplantation: a randomized, double-blind trial.
In a double-blind RCT of 100 liver transplant recipients with baseline K ≥4 mmol/L, nebulized salbutamol reduced the incidence of hyperkalemia 30 seconds after reperfusion compared with glucose–insulin (36% vs 56%; P=0.045). Salbutamol produced a greater potassium decrease, milder glycemic fluctuations, and lower postoperative atelectasis without increasing postreperfusion syndrome.
Impact: This trial provides actionable, intraoperative evidence to prevent a lethal electrolyte surge at graft reperfusion, potentially changing standard prophylaxis in liver transplantation.
Clinical Implications: Nebulized salbutamol can be considered as first-line prophylaxis to blunt reperfusion hyperkalemia in liver transplantation, especially when avoiding hyperglycemia is desirable or insulin–glucose is contraindicated.
Key Findings
- Hyperkalemia at 30 s after reperfusion was lower with salbutamol vs glucose–insulin (36% vs 56%; P=0.045).
- Maximum serum potassium decrease was greater with salbutamol (P<0.001), with the nadir at 45 min post-administration.
- Salbutamol led to milder blood glucose fluctuations, higher MAP and HR, lower driving pressure, and fewer postoperative atelectasis events; postreperfusion syndrome incidence was similar.
Methodological Strengths
- Randomized, double-blind design with a prespecified primary endpoint.
- Direct, clinically timed measurement at reperfusion with objective biochemical outcomes.
Limitations
- Single procedure context (liver transplantation) with short intraoperative time horizon; long-term outcomes not assessed.
- Sample size (n=100) limits subgroup analyses (e.g., donor types, severity of hyperkalemia).
Future Directions: Confirm in multicenter trials, evaluate optimal dosing/timing, interactions with citrate load and reperfusion hemodynamics, and assess clinical endpoints (arrhythmias, cardiac arrest, graft outcomes).
PURPOSE: Cardiac arrest due to a sharp increase in serum potassium one minute after reperfusion in liver transplantation (LT) is fatal. We sought to compare prophylactic nebulized salbutamol versus glucose-insulin for decreasing potassium during reperfusion and to guide the selection of potassium reduction strategies in LT. METHODS: We conducted a randomized, double-blind trial, enrolled patients undergoing LT with preoperative baseline serum potassium levels ≥ 4 mmol/L. Patients were randomized into two groups to receive either glucose-insulin (Group A) or nebulized salbutamol (Group B) as preventive potassium reduction regimens. The primary outcome was the incidence of hyperkalemia (defined as serum potassium > 5.5 mmol/L) 30 s after reperfusion (Rep1). RESULTS: One hundred participants were included in the analysis. The incidence of hyperkalemia at Rep1 was significantly lower in Group B than in Group A (36% vs. 56%, P = 0.045). Following administration and prior to reperfusion, the lowest potassium levels were achieved at 30 min in Group A and 45 min in Group B, respectively. The maximum decrease in the serum potassium level was significantly greater in Group B (P < 0.001). No significant differences in the incidence of postreperfusion syndrome were observed between the groups. Surprisingly, Group B had milder blood glucose fluctuations, higher heart rate and mean arterial pressure, lower driving pressure, and lower incidence of postoperative atelectasis. CONCLUSION: Nebulized salbutamol is superior to glucose-insulin for preventing acute hyperkalemia during the reperfusion period and may benefit patients undergoing LT. CLINICAL TRIAL NOTATION: Trial registration no. NCT05589441 ClinicalTrials.gov.
2. Endothelial cell responses in sepsis are attenuated by targeting truncated procalcitonin.
In murine sepsis models, neutralizing truncated procalcitonin reduced >50% of endothelial transcriptomic perturbations, preserved pulmonary and intestinal barrier integrity, mitigated vasoplegia, and improved organ-level outcomes. Mechanistically, benefits aligned with reduced IL-17 pathway signaling, positioning procalcitonin as a tractable endothelial-targeted intervention in sepsis.
Impact: Identifies a druggable, endothelial-centric pathway linking a clinically measured biomarker (procalcitonin) to vascular dysfunction in sepsis, offering a mechanistically grounded therapeutic strategy.
Clinical Implications: If translated to humans, anti-procalcitonin strategies could preserve endothelial barrier function and reduce vasoplegia in septic shock, complementing current hemodynamic and anti-infective therapies.
Key Findings
- Sepsis upregulated >2,000 pro-inflammatory endothelial genes and downregulated cell growth/maintenance programs.
- Anti-procalcitonin antibodies reduced endothelial transcriptomic changes by >50% and preserved lung/intestine barrier function with improved organ integrity.
- Mechanistic link to decreased IL-17 pathway signaling; reduced vasoplegia and preserved endothelial NO bioavailability in vivo.
Methodological Strengths
- Integrated transcriptomics with functional vascular readouts across organs in vivo.
- Mechanistic validation linking antibody neutralization to specific immune signaling (IL-17).
Limitations
- Preclinical models; human endothelial and clinical outcome validation are needed.
- Antibody specificity, dosing windows, and safety in septic phenotypes require translational study.
Future Directions: Define pharmacology and safety of procalcitonin neutralization in large animals and early-phase human studies; identify patient subgroups with endothelial activation where benefit is maximized.
Sepsis is associated with hypotension, vascular leakage, vasoplegia and microvascular dysfunction. Therefore, the endothelium is a target for sepsis therapies. Since truncated procalcitonin exerts vascular activity, we here evaluated the efficacy of targeting procalcitonin for vascular integrity and sepsis outcomes. Sepsis up-regulated >2000 genes involved in pro-inflammatory responses while similar numbers of genes involving cell growth and maintenance were down-regulated. Transcriptomic changes in endothelial cells diminished by >50% by anti-procalcitonin antibodies and this was functionally associated with preserved vascular barrier integrity in lungs and intestines, reduced sepsis-induced vasoplegia, preserved endothelial nitric oxide bioavailability, improved organ integrity and reduced sepsis severity in mice. Mechanistically, procalcitonin neutralization was associated with reduced signaling of the interleukin-17 pathway. We here show sepsis induces substantial changes to the endothelial transcriptome and vascular integrity and neutralizing procalcitonin is a suitable means to preserve endothelial homeostasis at a transcriptomic and functional level that could translate into organ protection during sepsis.
3. The effect of intraoperative hypotension on postoperative delirium: a meta-analysis and systematic review.
Across 18 studies, intraoperative hypotension was associated with higher postoperative delirium risk in both RCTs (RR 1.89) and observational studies (OR 2.48). Absolute hypotension thresholds and MAP-based definitions showed stronger associations, and meta-regression identified IOH threshold definitions as key heterogeneity drivers.
Impact: Synthesizes mixed literature to clarify the IOH–delirium link, informing blood pressure targets and standardization of IOH definitions in perioperative care and trials.
Clinical Implications: Supports maintaining intraoperative MAP above absolute thresholds to mitigate delirium risk, and underscores the need to standardize IOH definitions in protocols and quality metrics.
Key Findings
- IOH was associated with increased POD in RCTs (RR 1.89, 95% CI 1.31–2.74) and observational studies (OR 2.48, 95% CI 1.64–3.75).
- Absolute-threshold and MAP-based IOH definitions showed stronger associations (e.g., OR 4.11 and OR 2.90, respectively).
- Meta-regression identified IOH threshold definition as a significant effect modifier and a major source of heterogeneity.
Methodological Strengths
- Registered systematic review with comprehensive database search and stratified analyses by study design.
- Subgroup and meta-regression analyses to probe heterogeneity and effect modifiers.
Limitations
- Substantial methodological heterogeneity and variable IOH definitions limit causal inference.
- Some studies excluded due to non-extractable effect sizes or continuous exposure metrics.
Future Directions: Adopt standardized IOH thresholds and continuous MAP metrics in prospective trials testing delirium prevention; integrate cerebral autoregulation monitoring to personalize BP targets.
BACKGROUND: Postoperative delirium (POD) is a common complication linked to poor outcomes, yet its relationship with intraoperative hypotension (IOH) remains unclear. The objective of this study was to clarify the association between intraoperative IOH and POD. METHOD: We searched four databases (PubMed, EMBASE, Cochrane Library, and Web of Science) from their inception to June 14, 2025. Randomized controlled trials (RCTs) and observational studies were included when IOH was incorporated as a predictive variable for POD in adult patients undergoing elective surgery under general anesthesia. Risk ratio (RR) and odds ratio (OR) were calculated using a random-effect model separately in RCTs and observational studies. RESULTS: In total, thirty out of 1,261 studies were included for the systematic review, of which 18 studies were eligible for quantitative meta-analysis. The remaining 12 studies were excluded due to incompatible data formats: eight used continuous metrics, and four lacked extractable effect estimates. IOH was significantly associated with an elevated risk of POD in both RCTs (RR: 1.89, 95%CI: 1.31-2.74) and observational studies (OR: 2.48, 95%CI: 1.64-3.75). Subgroup analysis of observational studies revealed that IOH defined by absolute threshold (OR: 4.11, 95%CI: 2.05-8.24) and mean arterial pressure (MAP) (OR: 2.90, 95%CI: 1.56-5.39) was related to a higher risk of POD. This heterogeneity was further explored by meta-regression, which identified the threshold nature of the IOH definition as a significant source of heterogeneity and a key effect modifier ( CONCLUSION: Our meta-analysis demonstrates a statistically significant association between IOH and increased risk of POD. However, substantial methodological heterogeneity across the included studies limits the robustness of these findings. The current evidence should therefore be interpreted as exploratory, highlighting the need for more standardized investigations in this field. SYSTEMATIC REVIEW REGISTRATION: Identifier CRD42023424166.