Daily Anesthesiology Research Analysis
Analyzed 37 papers and selected 3 impactful papers.
Summary
Analyzed 37 papers and selected 3 impactful articles.
Selected Articles
1. Comparative effectiveness of intravenous remifentanil, epidural anesthesia and a two-step analgesic approach for external cephalic version: a large prospective single-center cohort study.
In a large single-center, three-phase prospective cohort of 2218 external cephalic version procedures, epidural anesthesia achieved the highest success (70%) and vaginal delivery rates with superior maternal pain control but increased maternal hypotension and some procedural complications. Remifentanil IV alone had lower success, while a two-step strategy improved outcomes compared with remifentanil alone but remained inferior to upfront epidural.
Impact: Directly informs analgesic strategy selection for external cephalic version with robust, clinically meaningful outcomes across >2000 procedures. Balances efficacy against safety, enabling nuanced shared decision-making.
Clinical Implications: For ECV candidates, a single, upfront epidural offers the highest likelihood of success and vaginal delivery but requires planning for hemodynamic monitoring and hypotension mitigation. A stepwise approach may suit patients prioritizing lower anesthesia-related risk while accepting potentially reduced success.
Key Findings
- Epidural anesthesia yielded the highest ECV success rate (70%) versus remifentanil IV (52.2%) and the two-step approach (65.2%).
- Vaginal delivery rates mirrored ECV success and maternal pain was substantially lower under epidural.
- Epidural increased maternal hypotension (16.1%) and some fetal heart rate abnormalities compared with remifentanil.
Methodological Strengths
- Large consecutive prospective cohort with standardized protocols and dedicated anesthesiologist presence.
- Direct comparison across three pragmatic strategies with clinically relevant endpoints (success, delivery mode, complications, pain).
Limitations
- Single-center, nonrandomized, time-sequenced phases introduce potential confounding (temporal trends, operator learning).
- Limited multivariable adjustment; generalizability may vary across settings and obstetric practices.
Future Directions: Prospective randomized trials comparing upfront epidural versus stepwise strategies with cost-effectiveness and patient-reported outcomes are warranted; protocols to mitigate epidural-associated hypotension should be tested.
BACKGROUND: Among the analgesic strategies used during external cephalic version, neuraxial anesthesia is the only approach that has consistently demonstrated higher vaginal delivery rates. However, neuraxial analgesia encompasses a heterogeneous range of techniques, and higher complication rates have been reported compared with other approaches. OBJECTIVES: This study aimed to compare the success of external cephalic version, modes of delivery, maternal pain, and complications using three strategies: intravenous analgesia with remifentanil, epidural anesthesia, and a stepwise approach in which epidural anesthesia was administered only if intravenous analgesia was unsuccessful. STUDY DESIGN: We conducted a single-center, consecutive three-phase cohort study including 1963 singleton pregnancies undergoing an external cephalic version: 558 with intravenous remifentanil (Group 1, 2012-2015), 665 with intravenous remifentanil followed by epidural anesthesia 2-3 days later if unsuccessful (Group 2, 2016-2019), and 730 under epidural anesthesia (Group 3, 2020-2024); yielding 2218 procedures, 1233 with intravenous remifentanil and 985 with epidural anesthesia. All procedures followed a standardized protocol, performed or supervised by experienced obstetricians, with continuous presence of anesthesiologists. Ritodrine was administered for tocolysis, or atosiban when contraindicated. Outcomes included success of the external cephalic version, mode of delivery, maternal pain (0-10 numerical scale), any analgesia-related complications, and procedural-related obstetric complications including vaginal bleeding, abnormal fetal heart rate patterns, hospital admission or any event that led to a delivery. Chi-square test was used for comparison, with significance at p<0.05. RESULTS: Success rates were highest with epidural anesthesia (70.0%, 511/730), compared with intravenous remifentanil (52.2%, 291/558) and the stepwise approach (65.2%, 440/675; p < 0.001). This was reflected in vaginal delivery rates of 72.2% (526/730), 64.0% (342/534), and 66.1% (444/672), respectively (p = 0.005). Maternal pain was substantially lower under epidural, with 78.3% of women reporting no or minimal pain, whereas this proportion fell to 49.2% in the remifentanil group and to 36.2% in the two-step approach (p < 0.001). Adverse effects of anesthesia were generally uncommon and clinically mild, but higher with epidural anesthesia (p < 0.001). Maternal hypotension was the main complication under epidural anesthesia (16.1%, 159/985), followed by dizziness (3.7%, 36/985), neither associated with significant obstetric clinical consequences. Procedural complications were rare, but more common with epidural anesthesia, and overall, highest among patients undergoing the two-step approach (p = 0.264). Vaginal bleeding occurred in 3.6% (35/985) of epidural cases and 4.3% (53/1233) with remifentanil (p = 0.052). Abnormal fetal heart rate patterns were more frequent with epidural (3.6%, 35/985) than remifentanil (1%, 12/1233) (p < 0.001). Procedure-related hospital admissions were uncommon and similar (3.6%, 35/985, vs 3.6%, 45/1233). Procedure-related deliveries and urgent cesareans were rare, but higher with epidural (1.4%, 15/985) than with remifentanil (0.5%, 6/1233) (p = 0.021). CONCLUSION: In this study, a single attempt with epidural anesthesia was the most effective strategy for external cephalic version, achieving the highest success and vaginal delivery rates while providing superior maternal pain control, but with higher complications. These findings may help support more informed counseling and shared decision-making when discussing analgesic options for external cephalic version.
2. The predictive value of tidal volume challenge-induced hemodynamic changes for fluid responsiveness in patients undergoing thoracoscopic surgery with one-lung ventilation: a prospective observational study.
In 60 VATS patients under lung-protective one-lung ventilation, TVC-induced changes in SVV and PPV predicted fluid responsiveness with good discrimination (AUC 0.83 and 0.86, respectively). Optimal cutoffs were >2% for ΔSVV_TVC and >3% for ΔPPV_TVC, and performance was unaffected by lateral decubitus side, though gray zones encompassed 22–38% of patients.
Impact: Provides actionable, bedside thresholds for predicting fluid responsiveness during OLV, where traditional dynamic indices often fail due to protective ventilation.
Clinical Implications: Consider implementing a brief tidal volume challenge during OLV to interpret ΔSVV_TVC (>2%) or ΔPPV_TVC (>3%) as supportive evidence for fluid responsiveness, while recognizing gray zones and integrating echocardiography/clinical context.
Key Findings
- ΔSVV_TVC AUC 0.83 (cutoff >2%; sensitivity 77%; specificity 76%) for predicting fluid responsiveness.
- ΔPPV_TVC AUC 0.86 (cutoff >3%; sensitivity 85%; specificity 80%); performance unaffected by lateral position.
- Gray zones were present (ΔSVV_TVC 1–3% in 38% of patients; ΔPPV_TVC 2–4% in 22%).
Methodological Strengths
- Prospective design with predefined protocol and clinical trial registration.
- Use of ROC analyses and device-based hemodynamics (LiDCO) under standardized OLV conditions.
Limitations
- Single-center study with modest sample size; external validity requires confirmation.
- Gray zones limit decisional certainty; findings may be device- or setting-specific.
Future Directions: Multicenter validation with different monitors and standardized TVC protocols; integrate TVC with echocardiographic indices and outcome studies (e.g., fluid balance, complications).
BACKGROUND: Video-assisted thoracic surgery (VATS) relies on one-lung ventilation (OLV) to achieve optimal surgical conditions. However, the lung protective ventilation strategies commonly employed during OLV diminish the accuracy of traditional dynamic parameters in predicting fluid responsiveness. The tidal volume challenge (TVC) has been proposed to overcome this limitation, yet its effectiveness in OLV patients remains to be validated. In this study, we used LiDCO to evaluate TVC-induced changes in SVV(ΔSVV_TVC) and PPV(ΔPPV_TVC), and assessed their ability to predict fluid responsiveness in patients receiving lung-protective OLV during VATS. METHODS: All patients received OLV in lateral position after general anesthesia induction. Upon achieving hemodynamic stability, the study protocol was initiated. Hemodynamic and respiratory parameters, including heart rate, mean arterial pressure, stroke volume variation (SVV), pulse pressure variation (PPV), stroke volume index (SVI), cardiac index, peak inspiratory pressure, and dynamic lung compliance were recorded at four time points: before TVC (T RESULTS: Among the 60 patients, 26 (43%) were fluid responders. ROC analysis showed that the area under the curve (AUC) of ΔSVV_TVC for predicting fluid responsiveness was 0.83 (95% CI, 0.71-0.91), with an optimal cutoff value of > 2%, sensitivity of 77%, specificity of 76%, and a gray zone range of 1%-3% encompassing 23 patients (38%). For ΔPPV_TVC, the AUC was 0.86 (95% CI, 0.74-0.93), with a cutoff of > 3%, sensitivity of 85%, specificity of 80%, and a gray zone of 2%-4% including 13 patients (22%).Subgroup analysis revealed no significant difference in the predictive AUC values of ΔSVV_TVC or ΔPPV_TVC between the left and right lateral decubitus positions. CONCLUSION: Tidal volume challenge -induced changes in SVV and PPV effectively predict fluid responsiveness in OLV patients, and their predictive performance is not influenced by patient position. TRIAL REGISTRATION: This trial was registered with Chinese Clinical Trial Registry, ChiCTR2300075285, August 31, 2023.
3. The Analgesic Effect of Extended Reality (XR) on Acute and Postoperative Pain in Children: A Systematic Review and Meta-Analysis.
Across nine studies (all VR), meta-analyses showed moderate-to-large but statistically nonsignificant reductions in self-reported and observer-reported pediatric acute/postoperative pain versus standard care. Heterogeneity and small sample sizes likely contributed to wide confidence intervals, underscoring the need for adequately powered RCTs with pain as a primary endpoint.
Impact: Provides a synthesis challenging assumptions that perioperative VR reliably reduces pediatric pain, highlighting methodological gaps and guiding future trial design.
Clinical Implications: Clinicians should view VR as adjunctive rather than definitive analgesia for pediatric acute/postoperative pain until higher-quality evidence emerges; prioritize multimodal analgesia and consider VR for engagement and anxiety reduction.
Key Findings
- Nine studies (seven postoperative, two acute) evaluated VR versus standard care in children.
- Self-reported pain meta-analysis (n=6) showed SMD -0.61 (95% CI -1.58 to 0.36), not statistically significant.
- Observer-reported pain meta-analysis (n=6) showed SMD -1.04 (95% CI -2.18 to 0.11), not statistically significant.
Methodological Strengths
- Comprehensive multi-database search with dual independent review and quality assessment (CONSORT, TREND).
- Use of validated pediatric pain measures and separate synthesis for self- and observer-reported outcomes.
Limitations
- Small number of studies with limited sample sizes and heterogeneity in VR content, timing, and patient ages.
- Exploratory meta-analyses with wide CIs; risk of publication and performance biases.
Future Directions: Conduct adequately powered, preregistered RCTs stratifying by age, VR modality, and timing, with pain as the primary endpoint and standardized outcome measures.
BACKGROUND: Acute and postoperative pain in children is often undertreated, with effects on patient comfort and postoperative recovery. Extended reality (XR) interventions offer non-pharmacological pain management by distracting patients from discomfort. While effective for procedural pain, its impact on prolonged pain episodes remains underexplored. OBJECTIVES: To systematically review and meta-analyze findings from previous studies on the efficacy of XR interventions in managing acute and postoperative pain in children, compared to standard care. ELIGIBILITY CRITERIA: Studies involving children (≤ 18 years) with acute or postoperative pain were included if they compared XR interventions to standard care. Studies focusing on procedural or chronic pain were excluded. METHODS: A systematic search was conducted on January 23, 2025, in MEDLINE, EMBASE, Web of Science, CINAHL, and PsycINFO for studies evaluating XR interventions for acute and postoperative pain in children, using validated pain measures. Pain outcomes were extracted for an exploratory meta-analysis, with self-report as the primary and observer-report as the secondary outcome. Two reviewers independently extracted data and assessed study quality using CONSORT and TREND. RESULTS: From 1793 records, nine studies were included, all evaluating virtual reality (VR) interventions. Seven focused on postoperative pain, two on acute pain. The primary meta-analysis (n = 6) showed a moderate but nonsignificant effect in self-reported pain (SMD = -0.61; 95% CI, -1.58 to 0.36). The secondary meta-analysis (n = 6) for observer-reported pain showed a large but nonsignificant effect (SMD = -1.04; 95% CI, -2.18 to 0.11). CONCLUSION: This meta-analysis found no significant analgesic effect of VR on acute or postoperative pain in children. However, moderate effect sizes were observed, but the lack of statistical significance indicates that XR interventions require further investigation in pediatric pain management. Future research should prioritize pain as a primary endpoint and assess the effects of VR type, timing, and age on acute pain using validated measures.