Daily Anesthesiology Research Analysis
Analyzed 76 papers and selected 3 impactful papers.
Summary
Analyzed 76 papers and selected 3 impactful articles.
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, immediate post-extubation rTMS to the left DLPFC reduced chronic postsurgical pain at 3 months (24.3% vs 43.5%; RR 0.56) and improved anxiety and depression scores. Lower serum CXCL10 levels in the active group and strong predictive accuracy of CXCL10 for CPSP (AUC 0.90) suggest an inflammation-related mechanism.
Impact: This sham-controlled RCT provides high-level evidence that neuromodulation can prevent chronic postsurgical pain and links clinical benefit to a mechanistic biomarker, advancing precision perioperative care.
Clinical Implications: rTMS could be integrated into perioperative pathways for older thoracic surgery patients as an adjuvant CPSP prevention strategy, with CXCL10 as a candidate risk-stratification biomarker. Multicenter replication and longer follow-up are needed before guideline adoption.
Key Findings
- Active rTMS reduced 3-month CPSP incidence versus sham (24.3% vs 43.5%; RR 0.56; P = 0.002).
- rTMS improved anxiety and depression scores at 3 months relative to sham.
- Serum CXCL10 levels were lower with rTMS, and CXCL10 predicted CPSP well (AUC 0.90; cutoff 90.5 pg/mL).
Methodological Strengths
- Randomized, sham-controlled design with blinded outcome assessment.
- Pre-specified stimulation parameters and biomarker analyses with quantitative metrics.
Limitations
- Single-center design with 3-month follow-up limits generalizability and long-term inference.
- Biomarker findings are exploratory; causal pathways require mechanistic validation.
Future Directions: Conduct multicenter, longer-term trials to confirm efficacy, optimize stimulation protocols, assess cost-effectiveness, and validate CXCL10-guided patient selection.
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 of 2,150 ARDS patients, the hazard from mechanical power depended on respiratory compliance and exposure duration. The authors integrated these effects into a risk-adjusted mechanical-power score that achieved AUROC 0.863, arguing against a single “safe” MP threshold and toward personalized, time-varying lung-protective ventilation.
Impact: Introduces a clinically interpretable, time-varying risk metric that unifies power intensity, duration, and compliance, challenging prevailing static thresholds for lung-protective ventilation.
Clinical Implications: Ventilator settings should consider compliance-stratified power bands and cumulative exposure rather than static MP cutoffs. The risk-adjusted MP score could underpin bedside decision support pending prospective validation.
Key Findings
- In higher-compliance lungs, risk increased dose-responsively starting at ~10 J/min with cumulative harm over time.
- In low-compliance lungs, risk was confined to a narrow 11–20 J/min band without cumulative harm.
- A risk-adjusted mechanical-power score predicted outcomes with AUROC 0.863 using eXtreme Gradient Boosting.
Methodological Strengths
- Large bi-national ICU datasets with time-dependent Cox models stratified by compliance.
- Integration of immediate and cumulative exposure effects into a unified, interpretable score with ML validation.
Limitations
- Retrospective design with potential residual confounding and lack of protocolized ventilator management.
- Outcomes included oxygenation worsening proxies; prospective clinical validation is needed.
Future Directions: Prospectively test the score in randomized or adaptive ventilation trials and embed it into real-time ICU decision support systems.
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 3,769,014 patients receiving 12,049,555 single-shot epidural injections, DSI occurred in 0.020% per injection. Older age, multiple comorbidities, recent immunosuppression/systemic steroids, ≥3 injections within 90 days, and lumbosacral-level injections increased risk, whereas selective nerve root block was protective.
Impact: Provides the most comprehensive, population-scale estimate of DSI risk after epidural injections with actionable, patient- and procedure-level risk factors to guide safer practice.
Clinical Implications: Use risk stratification to minimize DSI: limit injection frequency, exercise caution in immunosuppressed and multimorbid older adults, and consider selective nerve root blocks when appropriate; reinforce aseptic technique and postprocedure vigilance within 90 days.
Key Findings
- DSI incidence was 0.020% per injection across 12,049,555 injections.
- Risk increased with older age, multiple comorbidities, immunosuppressant/systemic steroid use, ≥3 injections within 90 days, and lumbosacral-level procedures.
- Selective nerve root block was associated with lower DSI risk (OR 0.49).
Methodological Strengths
- Nationwide claims-based cohort with over 12 million injections increasing statistical power and precision.
- Stringent DSI definition requiring hospitalization and ≥4 weeks of antibiotics to reduce misclassification.
Limitations
- Observational, claims-based design with potential residual confounding and limited clinical granularity (e.g., sterility technique, microbiology).
- Inability to capture infections treated entirely in outpatient settings without prolonged antibiotics.
Future Directions: Prospective registries linking procedural details, microbiology, and outcomes to refine risk models and test targeted prevention bundles in high-risk groups.
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.