Daily Anesthesiology Research Analysis

OBJECTIVE: To update evidence-based management recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with sepsis or septic shock. DESIGN: A panel of 68 international experts, representing 13 international organizations, as well as six methodologists, was convened. A formal conflict-of-interest policy was developed at the onset of the process and applied throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and subgroup leads, as well as within subgroups, served as an integral part of the guideline development process. METHODS: New priority topics and recommendations from the prior guideline iteration were used to identify Population, Intervention, Control, and Outcomes (PICO) questions likely to have new or updated evidence. We conducted a systematic review to identify the best available evidence, summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or conditional, or as a good practice statement. "In our practice," statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS: The panel provided 61 statements on the management of children with sepsis or septic shock. Overall, five were strong recommendations, 24 were conditional recommendations, and ten were good practice statements. For 22 PICO questions, no recommendations could be made, but for seven of these, "in our practice" statements were provided. Compared with the 2020 guidelines, 20 recommendations were new, 13 were updated for clarity and/or new evidence, six were reviewed but not changed, and 22 were carried forward based on consensus of the panel that new evidence was not available. Only three recommendations were based on high or moderate certainty of evidence. CONCLUSIONS: Updated management guidelines were issued by a panel of international experts for the best care of children with sepsis or septic shock, acknowledging that most aspects of care continue to have relatively low quality of evidence.

OBJECTIVE: This investigation systematically evaluated the antiemetic efficacy and safety of cipepofol for prophylaxis of postoperative nausea and vomiting (PONV) in surgical candidates with moderate to high Apfel risk. METHODS: A prospective, multicenter, randomized, parallel-group comparative trial was conducted at 18 clinical centers (N=594). Participants aged 18-60 years (ASA physical status I-III) with 2-4 Apfel risk factors undergoing elective noncardiac surgery were randomized into three anesthesia maintenance cohorts after cipepofol induction: cipepofol monotherapy (0.8 mg/kg/h), sevoflurane (1.5-2.0%), and combination therapy (cipepofol 0.4 mg/kg/h plus sevoflurane 1.0%). The primary endpoint was the incidence of PONV at 24 h postoperatively. Secondary endpoints included the incidence of PONV at 48 h postoperatively and intraoperative hemodynamic stability. RESULTS: Cipepofol monotherapy yielded a significantly lower 24-h PONV incidence (32.97% [95% CI, 27.1-39.2]) than sevoflurane (65.75% [59.4-71.6]; p<0.001). This difference persisted at 48 h (cipepofol: 35.68% [29.5-42.3]; sevoflurane: 69.06% [62.8-74.8]). A significantly lower proportion of patients required rescue antiemetic therapy in the cipepofol group than in the sevoflurane group within 48 h postoperatively (7.03% vs 16.02%, p=0.007). In addition, cipepofol was associated with a lower incidence of intraoperative hypotension than sevoflurane (9.73% vs 19.34%, p=0.009). CONCLUSION: Compared with sevoflurane alone, cipepofol significantly reduced PONV incidence at 24 and 48 h after surgery, with more stable intraoperative hemodynamics.

BACKGROUND: The anterior suprascapular nerve block (ASSB) is an alternative block to the interscalene block (ISB) for arthroscopic shoulder surgery. Notably, using ASSB can mitigate the incidence of hemidiaphragmatic paralysis while providing comparable analgesia to that achieved using ISB. However, hemidiaphragmatic paralysis still occurs in a considerable proportion of patients receiving a 10 mL local anesthesia dose. This study investigates whether reducing the local anesthetic volume to 5 mL in ASSB significantly lowers the incidence of hemidiaphragmatic paralysis. METHODS: Seventy-eight patients undergoing arthroscopic shoulder surgery were randomly administered either 5 mL (V5 group) or 10 mL (V10 group) of 0.5% bupivacaine for ultrasound-guided ASSB. The primary outcome was the incidence of hemidiaphragmatic paralysis 30 minutes after the block, as determined by ultrasound assessment of diaphragmatic excursion. Secondary outcomes were the time to first opioid request, 24-hour morphine consumption, block success rate, length of hospital stay, patient satisfaction, and pain scores determined in the PACU, 6, 12, and 24 hours after surgery. RESULTS: A total of 72 patients were eligible for analysis. All type of hemidiaphragmatic paralysis occurred in 33.33% of the patients in the V10 group and 5.56% of the patients in the V5 group (p = 0.006). Complete hemidiaphragmatic paralysis was observed in 16.67% of the V10 group and 0% of the V5 group (p = 0.025). There were no significant differences in secondary outcomes between the groups. CONCLUSION: Decreasing the volume of the ASSB from 10 to 5 mL of 0.5% bupivacaine effectively mitigated the risk of complete hemidiaphragmatic paralysis while maintaining comparable pain control.