Daily Anesthesiology Research Analysis
Analyzed 76 papers and selected 3 impactful papers.
Summary
Top findings span prevention, monitoring, and safety. An RCT showed early postoperative rTMS halved the incidence of chronic postsurgical pain after thoracoscopic surgery and implicated CXCL10 as a biomarker. A multicenter retrospective analysis reframed ventilator-induced lung injury risk with a risk-adjusted mechanical-power score that integrates power, exposure duration, and respiratory compliance. A nationwide cohort (3.8 million patients) quantified rare but serious deep spinal infection after single-shot epidural injections and identified modifiable risk factors.
Research Themes
- Noninvasive neuromodulation to prevent chronic postsurgical pain
- Personalized ventilator management using risk-adjusted mechanical power
- Risk stratification for deep spinal infection after epidural injections
Selected Articles
1. Early repetitive transcranial magnetic stimulation for preventing chronic postoperative pain in older adults: a randomized clinical sub-study.
In older adults undergoing thoracoscopic surgery, a single early postoperative rTMS session targeting the DLPFC reduced 3‑month CPSP (24.3% vs 43.5%; RR 0.56) and improved anxiety and depression scores. Serum CXCL10 levels were lower with active rTMS and showed strong predictive accuracy for CPSP (AUC 0.90), suggesting an inflammation-linked mechanism.
Impact: This randomized trial provides evidence for a noninvasive neuromodulation strategy to prevent CPSP and links clinical benefit to a plausible biomarker (CXCL10), advancing mechanism-informed perioperative pain prevention.
Clinical Implications: Early postoperative rTMS could be considered as an adjunct to multimodal analgesia to reduce CPSP in high-risk thoracoscopic surgery patients. CXCL10 may aid in risk stratification and treatment targeting, pending replication and protocol optimization.
Key Findings
- Active rTMS reduced CPSP incidence at 3 months (24.3% vs 43.5%; RR 0.56; 95% CI 0.39–0.80; P=0.002).
- Anxiety and depression scores were significantly improved at 3 months with rTMS.
- Serum CXCL10 levels were lower in the rTMS group and showed strong predictive accuracy for CPSP (AUC 0.90; cutoff 90.5 pg/mL).
Methodological Strengths
- Randomized, sham-controlled design with blinded outcome assessment (modified intention-to-treat).
- Integration of clinical outcomes with biomarker analysis (CXCL10) to explore mechanisms.
Limitations
- Single-center sub-study with 3-month follow-up; long-term durability and generalizability are uncertain.
- Optimal dosing, session number, and target parameters were not explored.
Future Directions: Multicenter RCTs to confirm effectiveness, define optimal rTMS protocols and dosing schedules, and evaluate biomarker-guided patient selection for CPSP prevention.
BACKGROUND: Chronic postsurgical pain (CPSP) is particularly relevant in thoracoscopic lung cancer surgery, a procedure predominantly performed in older adults, yet it remains a major clinical challenge with few effective preventive strategies. Repetitive transcranial magnetic stimulation (rTMS) has demonstrated analgesic potential and may offer a novel approach for CPSP prevention. This study investigated whether early postoperative rTMS could reduce CPSP in older patients undergoing thoracoscopic surgery and explored its potential mechanisms. METHODS: In this randomized controlled trial, 286 patients were screened and 230 undergoing thoracoscopic surgery were randomized to receive either active or sham rTMS targeting the left dorsolateral prefrontal cortex (10 Hz, 100% resting motor threshold, 2000 pulses per session) immediately after extubation in the PACU. A total of 198 patients completed the 3-month follow-up, during which clinical and biochemical outcomes were assessed by blinded evaluators. RESULTS: In the modified intention-to-treat analysis, the incidence of CPSP was significantly lower in the active rTMS group than in the sham group (24.3% vs 43.5%; RR, 0.56; 95% CI, 0.39-0.80; P = 0.002). In addition to reducing CPSP, active rTMS resulted in significant improvements in anxiety (26.0 [IQR, 25.0-26.0] vs 29.0 [IQR, 27.5-30.0]; P < 0.001) and depression scores (26.0 [IQR, 25.0-26.0] vs 29.0 [IQR, 27.5-30.0]; P < 0.001) at 3 months. Additionally, serum CXCL10 levels-an inflammation-related biomarker associated with chronic pain-were significantly lower in the active rTMS group (68.9 [48.1-85.7] vs 82.6 [67.3-105.5] ng/mL; P = 0.018). Exploratory analyses further demonstrated that CXCL10 had good predictive accuracy for CPSP (AUC = 0.90; cutoff = 90.5 pg/mL). CONCLUSIONS: Early postoperative rTMS targeting the DLPFC effectively reduces the development of CPSP after thoracoscopic surgery and may be associated with CXCL10-related inflammatory processes. CXCL10 may represent a promising candidate biomarker for identifying patients at high risk of CPSP. TRIAL REGISTRATION: ClinicalTrials.gov (NCT06392919).
2. Power, Duration, and Compliance: Reframing Risk of Ventilatory-Induced Lung Injury With the Risk-Adjusted Mechanical-Power Score.
Across 2 large ICU datasets in ARDS, risk from mechanical power exposure varied by respiratory compliance: dose-response with cumulative harm in higher-compliance lungs starting around 10 J/min, but a narrow risk band without cumulative effects in low-compliance lungs. A risk-adjusted mechanical-power score integrating intensity, duration, and compliance achieved AUROC 0.863 and offers a clinically interpretable, time-varying metric.
Impact: The study challenges the prevailing “single-threshold” approach to mechanical power, proposing a validated, compliance-adjusted and time-aware score that better reflects ventilator-induced injury risk.
Clinical Implications: Avoid applying uniform MP thresholds; instead, tailor ventilator settings by integrating respiratory compliance and exposure duration. The risk-adjusted MP score could inform personalized ventilation and monitoring, pending prospective validation.
Key Findings
- In higher-compliance lungs, immediate hazard began at ~10 J/min with clear dose-response and significant cumulative harm over time.
- In low-compliance lungs, risk was confined to a narrow band (11–20 J/min) without evidence of cumulative harm.
- The risk-adjusted mechanical-power score predicted outcomes with AUROC 0.863 using eXtreme Gradient Boosting.
- A single “safe” MP threshold was insufficient for guiding ventilation risk.
Methodological Strengths
- Two large ICU datasets (Netherlands and US) with time-dependent Cox modeling and compliance stratification.
- Integration of hour-specific exposure effects into a clinically interpretable, risk-adjusted score with ML validation.
Limitations
- Retrospective observational design with potential residual confounding and era effects.
- Requires prospective external validation and clinical workflow integration before implementation.
Future Directions: Prospective trials to validate the score, test algorithm-guided ventilation strategies, and assess impact on ventilator-induced lung injury and patient-centered outcomes.
OBJECTIVES: Static thresholds for mechanical power (MP) may not prevent ventilator-induced lung injury because risk depends on exposure duration and the underlying respiratory compliance. We aimed to quantify how MP intensity and exposure duration interact with respiratory compliance to predict oxygenation changes consistent with acute respiratory distress syndrome worsening or 14-day mortality. DESIGN: A retrospective analysis of 2 large intensive care datasets. SETTING: ICUs in the Netherlands and the United States from 2003 to 2016 and 2008 to 2019, respectively. PATIENTS: Mechanically ventilated adults with oxygenation levels consistent with moderate to severe acute respiratory distress syndrome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Time-dependent Cox proportional hazards models stratified by respiratory compliance estimated the hour-specific associations of immediate exceedance and cumulative time above MP thresholds with the primary outcome. Estimated effects were integrated into a risk-adjusted mechanical-power score. Among 2150 mechanically ventilated acute respiratory distress syndrome patients risk from MP exposure was dictated by respiratory compliance: in higher-compliance lungs, risk followed a dose-response pattern, with immediate hazard beginning at 10 J/min (hazard ratio = 1.04) and cumulative harm amplifying significantly over time. Conversely, for low-compliance patients, risk was confined to a narrow power band (11-20 J/min) without evidence of cumulative harm. With risk-adjusted MP score as a predictor of outcome eXtreme Gradient Boosting yielded an area under the receiver operating characteristic curve of 0.863. CONCLUSIONS: A single "safe" MP threshold is insufficient for guiding ventilation; the risk of lung injury is governed by a dynamic interplay of power intensity, duration, and the patient's respiratory compliance. The risk-adjusted MP score unifies these factors into a time-varying, clinically interpretable metric that warrants prospective validation for personalized ventilator management.
3. Prevalence and Risk Factors of Deep Spinal Infection after Single-Shot Epidural Injections: A Nationwide Cohort Study of 3.8 Million Pain Outpatients.
In a nationwide cohort spanning 12,049,555 epidural injections among 3,769,014 individuals, DSI occurred in 0.020% per injection. Risk increased with older age, multiple comorbidities, recent immunosuppressant/steroid use, ≥3 injections within 90 days, and lumbosacral-level injections, while selective nerve root block was protective.
Impact: This is the largest quantification of DSI risk after single-shot epidural injections, identifying actionable patient and procedural factors to inform safer pain interventions.
Clinical Implications: Use risk stratification before epidural injections, especially in older, comorbid, or immunosuppressed patients; minimize clustered injections; consider selective nerve root block when appropriate; enhance post-procedure surveillance.
Key Findings
- DSI incidence was 0.020% per injection across 12,049,555 injections.
- Risk factors included age ≥65, vascular/pulmonary/rheumatologic disease, peptic ulcer, liver disease, diabetes, recent immunosuppressant/steroid use, ≥3 injections in 90 days, and lumbosacral-level injections.
- Selective nerve root block was associated with lower DSI risk (OR 0.49; 95% CI 0.37–0.64).
Methodological Strengths
- Nationwide claims database with extremely large sample size and standardized DSI definition requiring hospitalization and prolonged antibiotics.
- Comprehensive multivariable adjustment for patient and procedural factors.
Limitations
- Administrative data subject to misclassification and unmeasured confounding; lacks microbiological and procedural sterility details.
- Very low event rate limits precision for some subgroups.
Future Directions: Prospective registries capturing procedural details, microbiology, and infection control practices; development of validated risk calculators to guide intervention selection and frequency.
BACKGROUND: Deep spinal infection (DSI) is a rare but potentially devastating complication of epidural injections. This study aimed to determine the nationwide incidence and risk factors of DSI following single-shot outpatient epidural injections for pain management. METHODS: Using customized data from the Korean National Health Insurance Service database, all patients who underwent single-shot outpatient epidural injections between 2009 and 2018 were identified. DSI was defined as a new-onset infection within 90 days of the most recent epidural injection that necessitated hospitalization and at least 4 weeks of antibiotic therapy. Multivariable logistic regression was performed to evaluate patient- and procedure-related risk factors. RESULTS: Among 12,049,555 injections in 3,769,014 individuals, 2,422 cases of DSIs were identified (0.020% per injection). In multivariable analysis, increased risk was associated with age ≥ 65 years (odds ratio [OR], 1.04; 95% CI, 1.04 to 1.05), peripheral vascular disease (OR, 1.38; 95% CI, 1.07 to 1.78), chronic pulmonary disease (OR, 1.33; 95% CI, 1.11 to 1.61), rheumatologic disease (OR, 1.85; 95% CI, 1.41 to 2.43), peptic ulcer disease (OR, 1.42; 95% CI, 1.22 to 1.66), liver disease (OR, 1.57; 95% CI, 1.34 to 1.83), diabetes (OR, 1.44; 95% CI, 1.14 to 1.81), recent immunosuppressant or systemic steroid use (OR, 2.44; 95% CI, 1.73 to 3.45), ≥ 3 injections within 90 days (OR, 1.93; 95% CI, 1.47 to 2.55), and lumbosacral-level injections (OR, 1.70; 95% CI, 1.45 to 2.00). In contrast, selective nerve root block was associated with a lower risk of DSI (OR, 0.49; 95% CI, 0.37 to 0.64). CONCLUSION: Although DSI after single-shot epidural injections is rare, its potential severity underscores the importance of careful patient selection and risk stratification, particularly in older patients, those with comorbidities or immunosuppression, and in procedures involving the lumbosacral level.