Daily Anesthesiology Research Analysis

BACKGROUND: Midazolam and dexmedetomidine are widely used sedatives for mechanically ventilated patients in the intensive care unit (ICU). However, their comparative effectiveness and safety remain debated. This systematic review and meta-analysis aimed to evaluate randomized controlled trials (RCTs) directly comparing these agents. METHODS: The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, The Cochrane Library, Web of Science, and Embase were searched through August 2025. Eligible studies were RCTs comparing midazolam with dexmedetomidine in adult ICU patients requiring invasive mechanical ventilation. Outcomes included mechanical ventilation duration, ICU length of stay, delirium, hemodynamic adverse events, and mortality. Pooled estimates were calculated using fixed- or random-effects models, with subgroup and sensitivity analyses performed to assess robustness. RESULTS: Fifteen RCTs with diverse international populations were included. Dexmedetomidine significantly reduced mechanical ventilation duration (WMD = -0.96 days, 95% CI: -1.56 to -0.36) and lowered delirium risk (RR = 0.59, 95% CI: 0.52-0.68). It was, however, associated with a higher incidence of bradycardia (RR = 2.05, 95% CI: 1.61-2.62). No significant differences were observed in ICU length of stay (WMD = -0.89 days, 95% CI: -2.41 to 0.62) or all-cause mortality (RR = 0.96, 95% CI: 0.79-1.18). Sensitivity analyses confirmed the stability of pooled results. Subgroup analyses suggested stronger benefits of dexmedetomidine in Asian studies and in smaller trials, while the protective effect against delirium was more pronounced in older patient cohorts. CONCLUSION: Dexmedetomidine demonstrated clinical advantages over midazolam by reducing delirium and ventilation duration but carried a greater risk of bradycardia. Sedative choice should balance efficacy with cardiovascular safety.

BACKGROUND: Effective postoperative pain control is essential for enhanced recovery after cardiac surgery, yet optimal multimodal strategies continue to evolve. The superficial parasternal intercostal plane (S-PIP) block has been proposed as a simple and safe technique for median sternotomy analgesia; however, current evidence remains fragmented, and its clinical impact is unclear. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials assessing the analgesic efficacy and safety of the S-PIP block in adult cardiac surgery. PubMed, Embase, CENTRAL, Web of Science, Scopus, ClinicalTrials.gov, and gray literature were searched through September 2025. Trials comparing S-PIP with standard or placebo analgesia were pooled using a random-effects model. The primary outcome was 24-hour opioid use (morphine milligram equivalents). Trial sequential analysis, meta-regression, and Grades of Recommendation, Assessment, Development, and Evaluation were applied to evaluate the robustness and certainty of evidence. RESULTS: Twenty-seven randomized controlled trials (1,760 patients) met the inclusion criteria. S-PIP block significantly reduced 24-hour opioid use compared with control (mean difference, -8.53 mg; 95% CI, -14.39 to -2.68), although the reduction was below the minimal clinically important difference and demonstrated substantial heterogeneity (I CONCLUSION: S-PIP provides modest early analgesic benefits after cardiac surgery. Further high-quality multicenter trials are required to clarify its overall clinical value.

PURPOSE: Despite extensive research, it remains unclear which patient-ventilator asynchronies are reliably detectable in clinical practice, most clinically relevant, and how they rank in severity. METHODS: Multiple-choice questions and 5-point Likert-scale statements were used in iterative Delphi rounds. Feedback was incorporated until stable consensus or dissensus was reached for all items. First series of rounds focused on identifying and classifying patient-ventilator asynchronies detectable from ventilator waveforms, second series assessed their associations with outcomes in three patient groups, and in the final rounds, asynchronies were ranked by severity within these patient groups and across three scenarios. RESULTS: In total, 11 panelists completed nine rounds. Consensus classified ineffective triggering, reverse triggering, double triggering, auto-triggering, insufficient flow, premature cycling, and delayed cycling as clinically relevant patient-ventilator asynchronies. Of these, auto-triggering and delayed cycling were deemed unlikely to be detectable using ventilator waveforms alone. Across all three patient groups, the panelists reached consensus that double triggering and ineffective triggering were the most clinically relevant. In acute respiratory distress syndrome, double triggering, ineffective triggering, and reverse triggering were all judged clinically relevant. In patients without acute respiratory distress syndrome and after cardiac surgery, asynchronies were classified as severe or mild and combined into two composite groups. CONCLUSION: This Delphi study provides a consensus-based framework for identifying and ranking patient-ventilator asynchronies at the bedside, highlighting those most likely to be clinically relevant and offering a structured approach to support monitoring, intervention, and future research.