Daily Anesthesiology Research Analysis
Analyzed 90 papers and selected 3 impactful papers.
Summary
Three impactful studies span critical care, nephrology, and perioperative pain. A large multinational RCT in pediatric septic shock found no difference in major adverse kidney events between balanced fluids and 0.9% saline, though electrolyte disturbances differed. Cohort work proposes a cystatin C-based AKI staging that outperforms creatinine for mortality risk, and a meta-analysis supports external oblique intercostal plane block as an opioid-sparing option after thoracoabdominal surgery.
Research Themes
- Fluid resuscitation strategies in pediatric septic shock
- Cystatin C-based staging to improve AKI detection and prognosis
- Regional anesthesia techniques to reduce postoperative opioid needs
Selected Articles
1. Balanced Fluid or 0.9% Saline in Children Treated for Septic Shock.
In a 47-ED multinational pragmatic RCT of pediatric septic shock, balanced crystalloids did not reduce MAKE30 compared with 0.9% saline, and hospital-free days were identical. Balanced fluids lowered hyperchloremia and hypernatremia but had slightly higher hyperlactatemia; safety outcomes were otherwise similar.
Impact: Sets high-quality evidence for pediatric septic shock fluid choice, showing no renal composite benefit with balanced fluids while clarifying electrolyte profiles.
Clinical Implications: Either balanced crystalloids or 0.9% saline are reasonable for initial pediatric septic shock resuscitation with no difference in MAKE30; balanced fluids may be preferred when hyperchloremia/hypernatremia are concerns, while monitoring for lactate changes.
Key Findings
- MAKE30 occurred in 3.4% (balanced) vs 3.0% (saline); risk ratio 1.10 (95% CI, 0.88–1.40; P=0.85).
- Hospital-free days (28-day window) were median 23 in both groups.
- Hyperchloremia: 31.4% (balanced) vs 49.0% (saline); hypernatremia: 1.8% vs 3.1%; hyperlactatemia: 19.8% vs 16.7%.
Methodological Strengths
- Large, multinational, pragmatic randomized trial across 47 EDs
- Pre-registered (NCT04102371) with clinically meaningful primary composite (MAKE30)
Limitations
- Pragmatic design may introduce variability in co-interventions and fluid dosing
- Low event rate may limit power to detect small differences; not blinded to fluid type
Future Directions: Explore patient subgroups (e.g., severe hyperchloremia risk, renal vulnerability) and longer-term outcomes; assess cost-effectiveness and protocolized fluid strategies.
BACKGROUND: Whether treatment with balanced crystalloid fluid leads to better outcomes than 0.9% saline in children treated for septic shock is debated. METHODS: In this pragmatic clinical trial conducted at 47 emergency departments in five countries, patients (2 months to <18 years of age) with suspected septic shock and abnormal perfusion were randomly assigned to receive fluid resuscitation with either balanced fluid or 0.9% saline for up to 48 hours. The primary outcome was a major adverse kidney event (a composite of death, new renal-replacement therapy, or persistent kidney dysfunction) at 30 days after enrollment or hospital discharge, whichever occurred first. RESULTS: Of 9041 enrolled patients, 277 (6.1%) in the balanced-fluid group and 282 (6.2%) in the 0.9%-saline group withdrew from the trial, leaving 4235 and 4247 patients, respectively, for analysis. A primary-outcome event occurred in 137 patients (3.4%) in the balanced-fluid group and in 124 (3.0%) in the 0.9%-saline group (difference, 0.4 percentage points; 95% confidence interval [CI], -0.5 to 1.3; risk ratio, 1.10; 95% CI, 0.88 to 1.40; P = 0.85). The median number of hospital-free days during 28 days after enrollment was 23 (interquartile range, 19 to 25) in both groups. Hyperchloremia occurred in 868 patients (31.4%) in the balanced-fluid group and in 1383 (49.0%) in the 0.9%-saline group; hypernatremia in 52 (1.8%) and 89 (3.1%), respectively; and hyperlactatemia in 260 (19.8%) and 228 (16.7%). No differences in other safety outcomes or adverse events were seen. CONCLUSIONS: Among children treated for septic shock, no significant difference was seen in the incidence of death, new renal-replacement therapy, or persistent kidney dysfunction when fluid resuscitation was administered with balanced fluid as compared with 0.9% saline. (Funded by Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; PRoMPT BOLUS ClinicalTrials.gov number, NCT04102371.).
2. Development and Validation of a Cystatin C-based Staging of AKI in Critically Ill Patients.
A cystatin C-based AKI staging mapped to mortality risk identified more AKI (and more Stage 3) than creatinine-based KDIGO in 9424 critically ill patients, with those reclassified by cystatin C showing mortality differences in both directions. External validation confirmed that upward reclassification independently predicted higher death risk.
Impact: Proposes an evidence-anchored, biomarker-based AKI staging that may improve early detection and prognostication beyond creatinine criteria.
Clinical Implications: In ICUs, adding cystatin C to AKI assessment may identify at-risk patients missed by creatinine and refine risk stratification; implementation will require assay availability, workflow integration, and prospective impact studies.
Key Findings
- Mapped cystatin C thresholds: Stage 1 (1.40–1.59× baseline within 7d or ≥0.44 mg/L within 48h); Stage 2 (1.60–2.09×); Stage 3 (>2.10× or ≥2.80 mg/L).
- Cystatin C-based staging identified 11% more AKI and 10% more Stage 3 than creatinine-based KDIGO.
- Reclassification by cystatin C from no AKI to AKI had higher death risk (HR 1.36), whereas reverse reclassification had lower risk (HR 0.71); validated externally.
Methodological Strengths
- Very large derivation cohort across three hospitals with long-term follow-up
- External validation and mortality-anchored threshold mapping
Limitations
- Observational design; potential residual confounding
- Assay standardization and timing variability may affect generalizability; no interventional testing
Future Directions: Prospective interventional studies to test cystatin C-guided AKI management, cost-effectiveness analyses, and integration into clinical decision support.
INTRODUCTION: Acute kidney injury (AKI) criteria and staging are based on serum creatinine and urine output, but serum cystatin C performs better at estimating glomerular filtration rate (GFR) in critically ill patients. Accordingly, a cystatin C-based AKI staging system was developed and its performance studied in critically ill patients. METHODS: AKI stages according to Kidney Disease: Improving Global Outcomes (KDIGO) creatinine criteria were converted to corresponding cystatin C-based stages using 14-day mortality in 9424 critically ill patients from 3 Swedish hospitals followed for 5.6 years (median interquartile range: 2.8-7.2). Model performance was evaluated using Cox regression on long-term mortality adjusted for age, gender, comorbidities, and unit type. An independent cohort ( RESULTS: KDIGO stages corresponded to the following: Stage 1: increase in cystatin C 1.40 to 1.59 times baseline within 7 days or ≥ 0.44 mg/l within 48 hours; Stage 2: 1.60 to 2.09 times baseline; and Stage 3: above 2.10 times baseline or ≥ 2.80 mg/l. Cystatin C-based versus creatinine-based staging identified 11% more AKI and 10% more Stage 3. Patients reclassified to AKI by cystatin C from no AKI had a higher risk of death of 1.36 (1.24-1.49), whereas those reclassified vice versa had a lower risk 0.71 (0.56-0.91). These findings were consistent irrespective of infection status for 30-day mortality. In the validation cohort, reclassification to a higher stage by cystatin C was an independent predictor of increased risk of death. CONCLUSION: In critically ill patients, cystatin C-based staging identified more AKI than KDIGO criteria, and these patients had increased short- and long-term mortality.
3. External Oblique Intercostal Plane Block for Postoperative Analgesia in Thoracoabdominal Procedures: A Systematic Review and meta-analysis.
Across 15 RCTs (n=899), external oblique intercostal plane block reduced 24-hour opioid consumption compared with standard care and with other regional techniques, albeit with moderate-to-high heterogeneity and low-to-very-low certainty for several pain outcomes. Findings support EOIPB as an option when first-line techniques are unsuitable or fail.
Impact: Synthesizes randomized evidence for a newer abdominal wall block with opioid-sparing potential across thoracoabdominal procedures.
Clinical Implications: EOIPB can be considered as part of multimodal analgesia when epidural is contraindicated or not feasible, recognizing heterogeneity and current low certainty; local protocols should incorporate clinician expertise and patient-specific factors.
Key Findings
- 15 RCTs with 899 patients were included under PRISMA and PROSPERO registration.
- EOIPB reduced 24-hour opioid consumption vs standard care (MD -19.55; 95% CI -28.50 to -10.60) and vs other regional blocks (MD -13.15; 95% CI -24.77 to -1.52).
- Study heterogeneity was moderate-to-high (I2 up to 95%), and GRADE rated many pain outcomes as low to very low certainty.
Methodological Strengths
- Prospectively registered systematic review (PROSPERO) following PRISMA
- Focus on randomized trials with quantitative synthesis and GRADE assessment
Limitations
- High heterogeneity across trials in patient selection, techniques, and outcome measures
- Overall low-to-very-low certainty for several outcomes; possible publication bias
Future Directions: Head-to-head, adequately powered RCTs with standardized EOIPB techniques, harmonized outcomes, and safety tracking to define its place versus epidural and other blocks.
OBJECTIVES: The primary objective was to analyze the efficacy of EOIPB in reducing use of opioids in postoperative period. Time and need for rescue analgesia, postoperative pain scores and incidence of nausea and vomiting were also evaluated. METHODS: The review followed the PRISMA guidelines and was registered on PROSPERO (CRD42024622945). Randomized clinical trials that included adults undergoing thoracoabdominal surgery, comparing EOIPB with general anesthesia, multimodal anesthesia, or other regional blocks, were selected. Search was performed on May 2025 in PubMed, Embase, Scopus, and Cochrane Library databases, with no time or language restrictions. Certainty of the evidence was assessed using GRADE system. RESULTS: Fifteen studies involving 899 patients were identified. Results indicated that EOIPB significantly reduced opioid consumption in the first 24 hours postoperatively, compared with standard analgesia (MD = -19.55; 95% CI [-28.50, -10.60]; P < 0.0001, I2 = 72%) and other regional blocks (MD = -13.15; 95% CI [-24.77, -1.52]; P = 0.03, I2 = 95%). Heterogeneity was considered moderate to high among studies, related to differences in samples, anesthetic protocols, and assessment methods. Outcomes associated with postoperative pain have a low to very low quality of evidence according to the GRADE method. DISCUSSION: The findings support the clinical potential of EOIPB as an effective strategy for postoperative pain control, but without indication for adoption in clinical practice routine, limited to situations of failure of first-line techniques in analgesia, such as epidural anesthesia.