Daily Anesthesiology Research Analysis

RATIONALE & OBJECTIVE: Patients admitted to the emergency department, the intensive care unit (ICU), and after cardiac surgery are at increased risk of developing adverse kidney events. Assessment of neutrophil gelatinase-associated lipocalin (NGAL) may facilitate renal risk prediction. However, the difference in NGAL-concentrations at admission in patients developing and not developing adverse events is unclear. STUDY DESIGN: An ancillary meta-analysis to a previous systematic review and meta-analysis using reanalyzed individual study-data from prospective clinical studies to compare NGAL concentrations measured using clinical laboratory platforms at patient admission. The study followed the Preferred Reporting Items for a Systematic Review and Meta-analysis of Individual Participant Data guideline. SETTING & STUDY POPULATIONS: Studies of adults investigating acute kidney injury (AKI) of all stages, severe AKI (stage injury or failure), and acute initiation of renal replacement therapy (RRT) in the setting of cardiac surgery, emergency department, or intensive care unit using either urinary or plasma NGAL concentrations measured on clinical laboratory platforms. SELECTION CRITERIA FOR STUDIES: Data inclusion was limited to the individual study-level data from the predecessor study. DATA EXTRACTION: This study used individual study-level data acquired using the protocol of a previous study, which was accomplished by individual authors' reassessment of their study data. ANALYTICAL APPROACH: Classification of AKI was harmonized among studies. Prespecified data comparison was performed for urine and plasma specimens for the outcome measures AKI, severe AKI, and acute RRT-initiation. Random effects meta-analyses were performed using the inverse variance method and the DerSimonian and Laird heterogeneity estimator. RESULTS: In total, 30 data sets from 26 studies were included. The estimated mean difference of urine NGAL concentrations was 125 (95% CI, 57.33-193.54) ng/mL for AKI, 317 (95% CI, 134.95-499.82) ng/mL for severe AKI, and 331 (95% CI, 71.36-592.06) ng/mL for RRT. For plasma NGAL concentrations, the estimated mean differences were 86.04 (95% CI, 51.74-120.34) ng/mL for AKI, 150.52 (95% CI, 80.27-220.76) ng/mL for severe AKI, and 129.83 (95% CI, 79.03-180.63) ng/mL for RRT. There were subgroup differences for the clinical setting, but not for the use of the urine output criterion. Multiple studies showed elevated NGAL concentrations in patients without serum creatinine concentration-based AKI, likely identifying patients with suspected AKI stage 1S (subclinical AKI). LIMITATIONS: Imperfect harmonization of data across studies because of their original protocols. CONCLUSIONS: NGAL concentration differences may facilitate identification of patients at risk of AKI or with suspected AKI stage 1S at admission. Heterogeneity and variability across studies, specimen types, and settings emphasize the importance of interpreting NGAL values within the specific clinical context and patient population. STUDY REGISTRATION: The International Database of Prospectively Registered Systematic Reviews reg. no.: CRD42016042735. Version of Record 1.2. Patients admitted to the intensive care unit, the emergency department, or following cardiac surgery are at increased risk of acute kidney injury (AKI). Neutrophil gelatinase-associated lipocalin (NGAL) is a biomarker that may help stratify AKI risk. This meta-analysis pooled and reanalyzed data from prospective studies measuring NGAL levels at patient admission and systematically compared them in those patients who developed AKI or required renal replacement therapy with those who did not. Higher NGAL levels were found to be associated with unfavorable outcomes. However, variability across studies and settings was observed. Interestingly, some patients showed elevated NGAL levels despite not being affected by serum creatinine-based AKI, suggesting NGAL levels may reflect subclinical AKI (stage 1S). These findings highlighted the need to interpret NGAL concentrations contextually within clinical settings.

INTRODUCTION: This study aimed to evaluate interventions that facilitate rapid extubation in adult cardiac surgery patients, defined as extubation within six hours, three hours, or one hour post-surgery. Early extubation is a critical component of enhanced recovery pathways in cardiac surgery and plays an essential role in improving patient outcomes. Several strategies have been investigated, including the use of locoregional anesthesia techniques, dexmedetomidine, and adaptive support ventilation. EVIDENCE ACQUISITION: A systematic review of randomized controlled trials (RCTs) was conducted, searching the Medline, Central, and Embase databases from January 2015 to May 2025. Studies were included if they compared interventions for rapid extubation and achieved extubation within at least one study group for more than 75% of patients. Fifty-seven trials were included in the review. EVIDENCE SYNTHESIS: Out of the 57 trials, 42 studies reported extubation within six to three hours post-surgery. These results were predominantly associated with locoregional anesthesia techniques, particularly fascial blocks, as well as dexmedetomidine use and adaptive support ventilation. Eleven studies reported extubation within three hours and one hour, with the majority of these trials also involving fascial blocks. Among the 57 studies, four focused specifically on ultrafast track strategies. Notably, only one study assessing the erector spinae plane block achieved extubation within one hour in over 75% of patients, with a median extubation time of 10 minutes (range 10-120 minutes), compared to 60 minutes (range 10-225 minutes) in the control group (P=0.06). CONCLUSIONS: While ultrafast extubation is currently limited to select patients, it appears to be safe and effective when carefully applied. The study supports the use of various interventions for facilitating rapid extubation and highlights the importance of individualized patient selection. Further high-quality trials are needed to identify the most effective combinations of these interventions and to standardize protocols for broader clinical practice.

OBJECTIVE: Propofol is widely used for gastrointestinal (GI) endoscopies but may cause respiratory depression and hemodynamic compromise when used alone. Adjuncts such as ketamine or esketamine and fentanyl-class opioids (fentanyl, alfentanil, and sufentanil) are used to optimize sedation, yet their comparative efficacy and safety remain uncertain. This meta-analysis evaluated ketamine or esketamine plus propofol (KP regimens) versus fentanyl/alfentanil/sufentanil plus propofol (FP regimens). METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically searched PubMed, Scopus, Cochrane Library, and Google Scholar from inception to February 2025 for randomized controlled trials (RCTs). Eligible studies included patients undergoing GI endoscopy (Population), receiving ketamine or esketamine with propofol (Intervention), compared with fentanyl-class opioids with propofol (Comparison), and reporting outcomes including propofol dose, comfort, adverse events, recovery time, or procedure time (Outcomes). Risk of bias was assessed with the Cochrane tool. Heterogeneity was evaluated using Cochran's Q test and the I2 statistic, and clinical heterogeneity was considered based on study design and population differences. Sensitivity analyses were conducted to test robustness of findings. RESULTS: Fifteen RCTs (1492 participants) were included. KP regimens significantly reduced total propofol use compared with FP (mean difference [MD] -0.42; 95% confidence interval [CI] -0.66 to -0.19; P = .0005), with greater benefit observed for esketamine (p for subgroup = 0.001). No significant differences were found in sedation (MD 0.01; 95% CI -0.40 to 0.43; P = .95) or pain scores (MD 0.24; 95% CI -0.18 to 0.65; P = .26). Safety outcomes were comparable across groups, with no significant differences in desaturation, nausea/vomiting, bradycardia, or tachycardia, except for hypotension, which was lower with KP (risk ratio [RR] 0.56; 95% CI 0.39 to 0.82; P = .003). Recovery and procedure times were similar between groups. CONCLUSIONS: Both KP and FP regimens are effective and safe for GI endoscopy. KP regimens reduce total propofol requirements and significantly lower the risk of hypotension, while showing comparable sedation quality, analgesia, and recovery profiles to FP. These findings suggest KP may offer safety and dosing advantages, though larger standardized trials are needed to confirm its clinical superiority.