Daily Anesthesiology Research Analysis
Analyzed 99 papers and selected 3 impactful papers.
Summary
Three impactful perioperative studies stood out: a rigorous cohort-plus–systematic review/meta-analysis identifies key risk factors for postoperative pneumonia after cardiac surgery; a multicenter RCT shows remimazolam reduces intraoperative hypotension vs propofol in older adults during colonoscopy; and a randomized trial finds early cytokine hemoadsorption in septic shock does not improve outcomes and may be harmful.
Research Themes
- Perioperative pulmonary complications and risk stratification in cardiac surgery
- Hemodynamic safety of sedatives in older adults
- Efficacy and safety of extracorporeal immunomodulation in septic shock
Selected Articles
1. Preoperative and Intraoperative Risk Factors for Postoperative Pneumonia After Cardiac Surgery: An Ancillary Study of the STERNOCAT (Catheter Outcomes With Sternotomy Cardiac Operated) Randomized Trial and a Systematic Review With Meta-Analysis.
In a 1,470-patient cohort, postoperative pneumonia occurred in 5.3% and was independently associated with ischemic cardiomyopathy, longer CPB duration, and catecholamine use; POP markedly increased 30-day mortality. A meta-analysis of 24 studies (n=172,079) identified 14 risk factors—mostly non-modifiable—while preoperative-only predictive models performed poorly on external validation.
Impact: This work integrates real-world cohort data with a systematic synthesis and external validation, clarifying risk factors for a high-impact complication after cardiac surgery and exposing limitations of current prediction models.
Clinical Implications: Prioritize perioperative optimization: minimize CPB duration, implement restrictive and judicious transfusion strategies, and intensify pulmonary prevention bundles in high-risk patients. Given poor model performance, rely on vigilant clinical assessment and targeted prevention rather than preoperative-only scores.
Key Findings
- POP incidence 5.3% in STERNOCAT cohort; 30-day mortality markedly higher with POP (14.1% vs 1.5%).
- Independent POP risk factors: ischemic cardiomyopathy (OR 1.89), longer CPB duration (OR 1.10), and catecholamine use (OR 4.07).
- Meta-analysis (24 studies; n=172,079) identified 14 risk factors; only four were partially modifiable (active smoking, CPB duration, intraoperative transfusions presence/amount).
- Only one preoperative-only prediction model could be externally validated and showed poor accuracy.
Methodological Strengths
- Combined single-center cohort analysis with a PROSPERO-registered systematic review and meta-analysis.
- External validation of published predictive models and multivariable adjustment in the cohort.
Limitations
- Cohort component was retrospective and subject to residual confounding.
- Heterogeneity among included studies; lack of interventional data to confirm modifiable targets.
Future Directions: Develop and test pragmatic, perioperative intervention bundles (e.g., CPB management, transfusion stewardship, smoking cessation) in multicenter trials; build and validate dynamic, perioperative prediction tools integrating intraoperative data.
OBJECTIVE: Postoperative pneumonia (POP) is a frequent complication after cardiac surgery, which significantly worsens prognosis. This study aimed to identify preoperative and intraoperative factors independently associated with POP in a cardiac surgery cohort, perform a systematic review (SR) and meta-analysis of risk factors, outcomes, and predictive models, and validate these models in the cohort. DESIGN: This is an ancillary study of the STERNOCAT (Catheter Outcomes With Sternotomy Cardiac Operated) trial completed by an SR and meta-analysis. PubMed, Embase, and Cochrane Library were searched (January 2000 to March 31, 2025). Two reviewers independently screened references to identify studies on adult cardiac surgery patients assessing POP risk factors or predictive models, extracted data, and assessed methodological quality. Predictive models identified through the SR were externally validated using the STERNOCAT cohort. SETTING: Cardiac surgery units in France (STERNOCAT cohort) and international hospital settings (SR studies). PATIENTS: A total of 1,470 patients from the STERNOCAT cohort and 172,079 from 24 studies overall were included in the SR. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In the STERNOCAT ancillary study, 78 of 1470 patients developed POP (5.3%). Independent risk factors included ischemic cardiomyopathy (odds ratio [OR] 1.89, 95% CI [1.13-3.16]), cardiopulmonary bypass (CPB) duration (OR 1.10, 95% CI [1.02-1.18]), and catecholamine use (OR 4.07, 95% CI [2.45-6.76]). POP was associated with higher 30-day mortality (14.1% vs. 1.5%, p < 0.0001). The meta-analysis identified 14 significant risk factors for POP. Of these, 10 were non-modifiable (e.g., age, diabetes mellitus, chronic obstructive pulmonary disease, chronic renal disease, previous cardiac surgery, emergency surgery). Four were partially modifiable: active smoking, CPB duration, intraoperative transfusions (presence and amount). Only one model, limited to preoperative variables, could be externally validated and showed poor accuracy. CONCLUSIONS: This study highlights the difficulty of predicting and preventing POP, as most identified risk factors are non-modifiable or require long-term preventive strategies. Perioperative optimization, particularly regarding CPB management and transfusion practices, therefore, remains essential to improving patient outcomes. REGISTRATION: PROSPERO (CRD42024555519).
2. Hemodynamic impact of remimazolam versus propofol during painless colonoscopy in older adults: A multicenter, single-blind, randomized controlled trial.
In 300 older adults undergoing colonoscopy, remimazolam significantly reduced intraoperative hypotension versus propofol (56.8% vs 82.6%) with faster sedation onset and better early post-awakening profiles; only the propofol group showed a significant cognitive score decline. Adverse events were similar between groups.
Impact: Provides randomized multicenter evidence supporting a hemodynamically safer sedative for older adults—an important, high-risk perioperative population.
Clinical Implications: Consider remimazolam as a preferred sedative for elderly colonoscopy to reduce hypotension and preserve early cognitive function; integrate into sedation pathways and ERAS endoscopy protocols.
Key Findings
- Intraoperative hypotension was significantly lower with remimazolam vs propofol (56.8% vs 82.6%, p<0.001).
- Faster time to MOAA/S ≤3 (1.17 vs 1.33 min; p=0.041) and lower Ramsay score 10 min post-awakening with remimazolam.
- Post-anesthesia cognitive scores declined in the propofol group (p=0.002) but not with remimazolam (p=0.658).
- No significant difference in treatment-related adverse events between groups.
Methodological Strengths
- Multicenter, randomized, single-blind design with adequate sample size (n=300).
- Clinically relevant endpoints (hypotension, sedation onset, cognitive assessment) with standardized scales.
Limitations
- Single-blind design may introduce performance bias; dosing ranges could allow variability.
- Limited to colonoscopy and ASA I–III; generalizability to longer or more invasive procedures is uncertain.
Future Directions: Head-to-head trials in higher-risk procedures and settings (e.g., longer endoscopy, non-endoscopy sedation), cost-effectiveness analyses, and comparative effects on postoperative cognitive trajectories.
BACKGROUND: Since older patients are at high risk of hypotension and hypoxia during anesthesia, it is crucial to choose safe sedatives. OBJECTIVES: To compare the efficacy and safety of remimazolam with propofol in elderly patients undergoing endoscopic procedures. MATERIAL AND METHODS: This multicenter, single-blind, randomized study included patients aged ≥65 years (American Society of Anesthesiologists (ASA) physical status I-III) who were randomized in a 1:1 ratio to receive either remimazolam (0.1-0.2 mg/kg) or propofol (0.3-0.5 mg/kg). The primary endpoint was the rate of occurrence of hypotensive events. Secondary endpoints included time to patient unresponsiveness and time to awakening (defined as a Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score ≤3 and ≥4), time to leaving the operating room, cognitive function assessment (using the Mini-Cog test), and additional parameters. RESULTS: A total of 300 patients aged ≥65 years were enrolled. Patients who received remimazolam (n = 132) experienced a significantly lower incidence of intraoperative hypotension compared with those treated with propofol (n = 138) (56.8% vs 82.6%, p < 0.001). The median time to reach a MOAA/S score of 3 was shorter in the remimazolam group than in the propofol group (1.17 min [interquartile range (IQR): 0.85-1.44] vs 1.33 min [IQR: 0.88-2.00], p = 0.041). At 10 min post-awakening, the median Ramsay sedation score was lower in the remimazolam group (2.03 ±0.17 vs 2.14 ±0.35, p = 0.001). Tukey's post hoc analysis showed a significant decline in cognitive scores before and after anesthesia in the propofol group (p = 0.002), whereas no significant change was observed in the remimazolam group (p = 0.658). There was no significant difference in treatment-related adverse events (AEs) between the 2 groups. CONCLUSIONS: Remimazolam significantly reduced the incidence of intraoperative hypotension during colonoscopy, providing a safer sedative option for elderly patients and supporting its use as a preferred agent in this population.
3. Clinical and Immunologic Effects of Extracorporeal Cytokine Removal in Patients with Septic Shock: A Randomized Controlled Trial.
In a randomized trial of 31 hyperinflammatory septic shock patients, adding CytoSorb hemoadsorption to guideline-based care did not reduce cumulative norepinephrine at 72 hours and was associated with higher vasopressor dose per hour alive and lower 48- and 72-hour survival. Cytokine profiles were similar between groups, with a lower lymphocyte percentage in the hemoadsorption arm.
Impact: This negative randomized trial challenges routine use of cytokine hemoadsorption in septic shock, highlighting potential early harm and reinforcing adherence to evidence-based sepsis care.
Clinical Implications: Avoid routine early hemoadsorption in septic shock outside clinical trials; focus on timely source control, antibiotics, fluids, and individualized vasopressor strategies. Monitor lymphocyte trends if hemoadsorption is used within studies.
Key Findings
- Primary endpoint not improved: 72-hour cumulative norepinephrine 78 mg (control) vs 100.7 mg (hemoadsorption), p=0.09.
- Higher vasopressor dose per hour alive with hemoadsorption (2.5 vs 1.2 mg; p=0.0053).
- Lower 48- and 72-hour survival in the hemoadsorption group (p=0.01 and p=0.03).
- No significant differences in pro/anti-inflammatory cytokines; lower lymphocyte percentages with hemoadsorption.
Methodological Strengths
- Randomized controlled design with early initiation (within 24 h) and biologically enriched population (IL-6 > 500 pg/mL).
- Predefined clinical and immunologic endpoints with pragmatic standard-of-care comparator.
Limitations
- Single-center, small sample size limits power and generalizability.
- Potential imbalances and early survival differences warrant cautious interpretation.
Future Directions: If pursued, larger multicenter RCTs with adaptive designs should target phenotyped subgroups and hard outcomes; mechanistic studies to identify responders and immunologic signatures are needed.
BACKGROUND: Immune dysregulation and excessive cytokine release characterize the early phase of septic shock. Extracorporeal hemoadsorption with the CytoSorb® device aims to restore immune balance by removing inflammatory mediators. Currently clinical benefits remain uncertain. METHODS: In a single-center randomized controlled trial, 31 adult patients with septic shock, extracorporeal circuit and Interleukin-6 > 500 pg/ml were included. The control group received standard care according to sepsis guidelines. The intervention group received standard care plus CytoSorb hemoadsorption. The primary outcome was the cumulative norepinephrine dose over 72 hours. Secondary outcomes included clinical and immunological endpoints. RESULTS: Between February 2022 and July 2023, 58 patients with septic shock and hyperinflammation were screened for study inclusion. 17 patients were randomized to the control group, 14 patients received extracorporeal cytokine removal. Hemoadsorption started within 24 h after onset of septic shock in 93 % of cases. The cumulative norepinephrine dose in 72 hours was 78 mg (52.7 - 117.8 mg) in the control group and 100.7 mg (66.4 - 190.8 mg) with extracorporeal cytokine removal (p = 0.09). The total vasopressor dose per hour alive in the first 72 hours was significantly lower in the control group compared to extracorporeal hemoadsorption (1.2 mg, 0.8 - 2.0 mg versus 2.5 mg, 1.7 - 3.3 mg; p = 0.0053). Survival at 48 hours (100 %, n = 17/17 versus 64 %, n = 9/14; p = 0.01) and 72 hours (94 %, n = 16/17 versus 57 %, n = 8/14; p = 0.03) after onset of septic shock was higher in the control group. ICU mortality, length of stay, duration of septic shock, and other clinical outcomes did not differ between the groups. The humoral immune response including pro- and anti-inflammatory cytokines was similar between groups. Compared to controls, patients with extracorporeal cytokine removal had significantly lower lymphocyte percentages during the first three days of septic shock (6.2 %, 5.0 - 17.4 % versus 2.5 %, 2.1 - 5.6 %; p = 0.04), whereas leukocyte and lymphocyte subsets as well as cytotoxic capacities were not altered by hemoadsorption. CONCLUSION: Early initiation of extracorporeal hemoadsorption in patients with septic shock did not improve vasopressor requirements or clinical outcomes and no effects on the immune response were observed.