Daily Anesthesiology Research Analysis

INTRODUCTION: Selection and dosing of surgical antimicrobial prophylaxis (SAP) to prevent surgical site infections (SSIs) is variable and often inappropriate in clinical settings resulting in increased risk of SSI. We therefore developed and implemented a novel computer decision-support tool to improve appropriate SAP selection specific to each patient's procedure and clinical context. METHODS: The intervention, performed at a multi-site tertiary hospital network, was a computer decision-support tool programmed within the hospital's electronic health record (EHR) to provide patient-specific SAP recommendations based on four variables: procedure name, patient's beta-lactam allergy status, MRSA status and weight. Safety of cefazolin prophylaxis among patients with self-reported beta-lactam allergy was established in the pre-operative clinic using a validated simple two-item questionnaire. Before each operation, a best practice SAP recommendation alert was provided to the anaesthesiologist based on the inputs from the four aforementioned variables. RESULTS: In the post-intervention period of 2 years, a total of ∼110 recommendation alerts were logged. A random sample audit of 408 surgical encounters were selected from the pre- and post-intervention periods. Overall, appropriate antibiotic administration rose from 77% (161/208) to 92.5% (185/200) (χ2 = 18.0, P < 0.001) post-intervention. Significant improvements were made for procedure-specific antibiotic selection (80.5% versus 94.5%; χ2 = 19.3, P < 0.001) and weight-based dosing (92.5% versus 98.4%; χ2 = 7.45, P = 0.006). Using National Surgical Quality Improvement Program (NSQIP) auditing of 21 912 surgeries showed a significant decline in SSIs following the implementation of the intervention in June 2022. CONCLUSION: In this first-ever intervention designed to direct SAP prescribing based on patient-specific variables, we significantly improved appropriate SAP selection and reduced SSIs across a comprehensive list of surgical procedures.

BACKGROUND: The estimated incidence of acute kidney injury requiring renal replacement therapy (RRT), mainly continuous RRT (CRRT), in patients necessitating extracorporeal membrane oxygenation (ECMO) is approximately 50%. Currently, two well-known techniques, integration and separation, are utilized for combining CRRT and ECMO circuits, neither of which is considered a standard treatment. PURPOSE: This study aimed to compare circuit lifespan of CRRT between these two techniques during ECMO support. METHODS: A multicentered randomized controlled trial was conducted from May 2021 to March 2025. ECMO patients who required CRRT support were enrolled. Primary outcome was CRRT circuit lifespan. RESULTS: Eighty patients were recruited, with 40 allocated to the integration group and 40 to the separation group. Median circuit lifespan did not significantly differ between the groups (72 h [IQR 45-96.5] vs. 71 h [IQR 45-84]; p = 0.52). Twenty-eight-day mortality rates were also comparable (32.5% vs. 35%; p = 0.81). No significant differences were observed in the incidence of serious adverse events, including air embolism. Transmembrane pressure and CRRT machine alarm frequencies were similar between groups. CONCLUSION: Among critically ill ECMO patients receiving CRRT, there is no significant difference in filter lifespan and serious adverse events between integrating the CRRT circuit into the ECMO circuit and using a separate circuit. TRIAL REGISTRATION: NCT05036616.

BACKGROUND: Since current opioid overdose deaths occur mainly from potent synthetic opioids with high affinity for the opioid receptor, such as fentanyl and carfentanil, it is important to determine the efficacy of naloxone, particularly the intranasal formulation, in reversing opioid-induced respiratory depression. This study evaluated effectiveness of 4 mg intranasal naloxone (Narcan®) in reversing moderate respiratory depression induced by fentanyl and sufentanil, in opioid-naïve individuals and self-reported daily opioid users. Sufentanil was compared to fentanyl because of its higher affinity for the opioid receptor than fentanyl. METHODS: In this prospective, crossover trial, 12 opioid-naïve individuals and 18 daily opioid users (morphine milligram equivalent of 291 (range 60-2250 mg/day) received continuous fentanyl or sufentanil infusions, titrated to achieve 30-40% reduction in ventilation (V̇E). Participants were administered Narcan® during steady-state respiratory depression. Primary endpoints included time to reversal of diminished V̇E and elevated end-tidal carbon dioxide concentration (pCO2). RESULTS: Narcan® restored V̇E within 2-4 min across all participants but showed delayed reversal of end-tidal pCO2 (11-17 min), with pCO2 recovery during sufentanil exposure in just 8 opioid-naïve individuals and 10 daily opioid users. Hysteresis analysis showed for V̇E-reversal onset/offset time (blood-effect-site equilibration half-life) of 0-1 min and end-tidal pCO2 2-11 min. Because of withdrawal symptoms, seven of eighteen daily opioid users participated once in the study. Study limitations included continuous opioid infusions that do not occur in real-world overdose settings. CONCLUSION: A single Narcan® dose reversed moderate fentanyl- and sufentanil-induced respiratory depression, though effectiveness varied by endpoint and opioid receptor affinity. Rapid V̇E-recovery suggests clinical utility of intranasal naloxone, but delayed and sometimes incomplete recovery of end-tidal pCO2, particularly during exposure to the high-affinity opioid sufentanil, indicating reversal inefficacy and persistence of respiratory instability. Further studies are needed to address optimal naloxone doses and alternative formulations to address high-dose potent opioid threats.