Daily Anesthesiology Research Analysis
Analyzed 52 papers and selected 3 impactful papers.
Summary
Analyzed 52 papers and selected 3 impactful articles.
Selected Articles
1. Evaluation of clinical impact of ultra fast-track versus conventional extubation in patients undergoing nonemergency cardiac surgery: 'CARDU-FAST': A randomised clinical trial.
In 612 randomized cardiac surgery patients, ultra fast-track extubation did not significantly reduce a composite of mortality, major respiratory complications, and AKIN III versus early ICU extubation. However, it shortened ICU and hospital lengths of stay and reduced prolonged intubation, need for noninvasive ventilation, reoperations for bleeding, and postoperative low cardiac output syndrome.
Impact: This large randomized trial clarifies safety and potential recovery benefits of ultra fast-track extubation in contemporary cardiac anesthesia pathways.
Clinical Implications: Ultra fast-track extubation can be considered in carefully selected nonemergency cardiac surgery patients to improve resource utilization and recovery metrics without increasing adverse events.
Key Findings
- Primary composite outcome: 6.5% (UFT) vs 10.1% (FT), P=0.105 (not significant).
- Prolonged intubation >24 h: 2.0% (UFT) vs 7.5% (FT), P=0.001.
- Reduced need for noninvasive ventilation: 5.6% (UFT) vs 11.1% (FT), P=0.013.
- Fewer reoperations for bleeding: 2.6% (UFT) vs 6.9% (FT), P=0.013.
- Shorter ICU and hospital length of stay in UFT group.
Methodological Strengths
- Randomized design with intention-to-treat analysis.
- Pre-registered trial with standardized perioperative management.
Limitations
- Single-center, open-label design limits generalizability and blinding.
- Primary composite outcome not significantly different; potential for type II error for rare events.
Future Directions: Multicenter RCTs powered for major outcomes, refined selection criteria, and cost-effectiveness analyses to define which patients benefit most from ultra fast-track extubation.
BACKGROUND: Immediate extubation in the operating theatre (Ultra Fast-Track, UFT), compared with early extubation in the intensive care unit (ICU) (Fast-Track, FT), has been proposed as a strategy to improve postoperative recovery after cardiac surgery. However, its effect on major clinical outcomes remains unclear. OBJECTIVE: To compare the risk of a composite outcome including perioperative all-cause mortality, respiratory complications, and acute kidney injury between UFT and FT in patients undergoing major nonemergency cardiac surgery. DESIGN: Single-centre, randomised clinical trial conducted between February 2023 and November 2024. SETTING: A tertiary cardiovascular centre with standardised perioperative and anaesthetic management. PARTICIPANTS: A total of 612 adult patients undergoing major cardiac surgery were randomised to UFT (n = 306) or FT (n = 306). INTERVENTION: Patients in the UFT group were extubated in the operating theatre, whereas patients in the FT group underwent early extubation in the ICU. MAIN OUTCOMES AND MEASURES: The primary endpoint was a composite outcome of all-cause mortality, respiratory complications (prolonged intubation >24 h, reintubation, pneumonia), and stage III acute kidney injury (AKIN III). RESULTS: The primary composite endpoint occurred in 6.5% of patients in the UFT group and 10.1% in the FT group, with no statistically significant difference (P = 0.105). Compared with FT, UFT was associated with shorter ICU and hospital length of stay, lower rates of prolonged intubation (2.0 versus 7.5%; P = 0.001), reduced need for noninvasive ventilation (5.6 versus 11.1%; P = 0.013), fewer reoperations for bleeding (2.6 versus 6.9%; P = 0.013) and a lower incidence of postoperative low cardiac output syndrome. CONCLUSIONS: Although UFT did not significantly reduce the primary composite outcome in the intention-to-treat (ITT) analysis, it was not associated with an increased risk of adverse events but was associated with improvements in several secondary outcomes. These findings suggest potential benefits of UFT in carefully selected cardiac surgery patients. TRIAL REGISTRATION: Evaluation of clinical impact of UFT versus conventional extubation in patients undergoing cardiac surgery. CARDU-FAST clinical trial. ClinicalTrials.gov Identifier: NCT05706857.
2. Peripheral Nerve Blocks Following Open Hepatectomy: A Systematic Review and Network Meta-Analysis.
Across 17 RCTs (n=1056), continuous TAP and continuous thoracic paravertebral blocks most reduced 24-hour morphine consumption after open hepatectomy. ESPB and TANB provided better early pain control and were associated with reduced PONV. Certainty of evidence was low to moderate, and clinical differences between techniques were small.
Impact: Provides comparative effectiveness evidence to guide selection of regional anesthesia techniques for open hepatectomy analgesia.
Clinical Implications: When feasible, continuous TAP or continuous paravertebral blocks can be prioritized to reduce opioid consumption, while ESPB or TANB may be favored for early pain relief and PONV reduction. Standardization and local expertise remain essential.
Key Findings
- cTAPB and cTPVB significantly reduced 24-hour morphine consumption after open hepatectomy.
- ESPB and TANB reduced resting VAS at 6 hours; ESPB and sTAPB at 12 hours; TANB and cTAPB at 24 hours.
- Movement VAS improved with ESPB and cTPVB at 6 h, ESPB and sTAPB at 12 h, and TANB and EOIPB at 24 h.
- ESPB and TANB were associated with reduced postoperative nausea and vomiting.
- Certainty of evidence was low to moderate; clinical differences between techniques were small.
Methodological Strengths
- Network meta-analysis synthesizing 17 randomized controlled trials.
- Comprehensive assessment across eight regional techniques with multiple pain timepoints.
Limitations
- Heterogeneity in study designs and analgesic protocols; low-to-moderate certainty of evidence.
- Findings may not generalize to laparoscopic hepatectomy; potential publication bias.
Future Directions: Conduct head-to-head, adequately powered RCTs with standardized multimodal protocols and patient-centered outcomes to resolve small effect differences and validate rankings.
BACKGROUND: This network meta-analysis (NMA) was conducted to evaluate the analgesic efficacy of various nerve blocks in patients undergoing open partial hepatectomy. METHODS: We retrieved randomized controlled trials (RCTs) assessing different peripheral nerve blocks in patients undergoing open partial hepatectomy from databases including PubMed, Embase, Web of Science, and the Cochrane Library, spanning from inception until December 2025. The NMA was performed using STATA 17.0 software. RESULTS: A total of 17 RCTs involving 1056 patients and 8 techniques were included in the analysis. Continuous Transversus Abdominis Plane Block (cTAPB) and continuous Thoracic Paravertebral Block (cTPVB) significantly decreased morphine consumption within 24 hours. The Erector Spinae Plane Block (ESPB) and Thoracoabdominal Nerve Block (TANB) reduced resting Visual Analog Scale (VAS) scores at 6 hours. At 12 hours, resting VAS scores were decreased by ESPB and subcostal Transversus Abdominis Plane Block (sTAPB), while at 24 hours, resting VAS scores were lowered by TANB and cTAPB. For movement VAS scores, reductions were observed at 6 hours with ESPB and cTPVB, at 12 hours with ESPB and sTAPB, and at 24 hours with TANB and External Oblique Intercostal Plane Block (EOIPB). Additionally, ESPB and TANB were associated with a decrease in the incidence of postoperative nausea and vomiting (PONV). CONCLUSION: While cTAPB and cTPVB ranked higher in terms of reducing 24-hour morphine consumption, the clinical difference between these techniques and other interventions was small. ESPB was more likely to reduce VAS within the first 12 hours and the PONV incidence. Nevertheless, the certainty of evidence for these findings remains low to moderate, and further high-quality randomized controlled trials are warranted to confirm their clinical utility. LIMITATION: The studies included in our review exhibited inconsistencies in study design and analgesia protocols, which may introduce bias into our findings. The results may not be directly applicable to laparoscopic procedures. The absence of these unpublished data or ongoing trials could limit the comprehensiveness of our analysis.
3. Risk-Reduction by direct thrombin antagonism during ECMO therapy.
In a prospective multicenter cohort of 254 ECMO patients, direct thrombin antagonists were non-inferior to heparin for thrombosis, circuit occlusions, weaning, and survival. After switching from heparin to direct thrombin antagonists, overall complications and bleeding were reduced, suggesting a potential safety advantage in HIT II–prone contexts.
Impact: Addresses a critical anticoagulation question during ECMO with real-world multicenter data, suggesting a feasible alternative when heparin is problematic.
Clinical Implications: Direct thrombin antagonists can be considered when heparin is contraindicated or HIT II is suspected during ECMO, with careful monitoring and institutional protocols.
Key Findings
- No difference between heparin and direct thrombin antagonists in thrombosis and circuit occlusions.
- Non-inferior weaning from ECMO and survival outcomes with direct thrombin antagonists.
- After switching from heparin to direct thrombin antagonists, overall complication rates and bleeding were lower (superiority signal).
- Anticoagulation switch was triggered by suspected HIT II and platelet count reduction (p=0.017 for reduction).
Methodological Strengths
- Prospective multicenter cohort spanning cardiothoracic, pulmonary, and anesthesiological ICUs.
- Includes both venoarterial and venovenous ECMO populations, enhancing external validity.
Limitations
- Non-randomized design susceptible to confounding by indication and temporal biases.
- Some reporting details (e.g., country) are redacted; anticoagulation monitoring protocols not fully specified.
Future Directions: Randomized controlled trials comparing direct thrombin antagonists vs heparin during ECMO, with standardized monitoring (e.g., anti-IIa/anti-Xa assays) and bleeding/thrombotic end points.
BACKGROUND: ECMO-patients can develop heparin (Hep)-induced-thrombocytopenia Type II (HITII). Approval for direct thrombin-antagonism is lacking. We analyze if direct thrombin antagoism feasible, save and not inferior to heparin. METHODS: 254 multicenter prospective patients (vv- or va-ECMO) were analyzed in 4 different cardiothoracic, pulmonary, or anesthesiological intensive care units at university hospitals in XXXXXXX from 2020 to 2022. RESULTS: 153 va-ECMO / 101 vv-ECMO patients always received heparin (95/43), only DTA (8/6) or a switch (50/52) from heparin to direct thrombin antagonism (DTA) in cases of suspected HITII and reduced platelet count (reduction: p =0.017). ICU morbidity, survival, therapeutic stability of anticoagulation, bleeding, thrombosis and technical integrity was analyzed regarding non inferiority and superiority of DTA versus heparin. Patients who changed anticoagulation showed increased infection levels before the change. Before switching from heparin to DTA, there was only a moderate increase in the INR, a decrease in the Quick and no therapeutic increase in the PTT with heparin. With regard to thrombosis and system occlusions, there is no difference between heparin and DTA. Weaning rates from extracorporal support and survival analysis did show non-inferiority of DTA. After switching a clear superiority of DTA in terms of (A) overall complication rate CI((0.6479/0.7871/0.9546)) (defined as bleeding from any cause, stroke, amputation, thrombosis and device-occlusion) and (B) bleeding from any cause alone CI((0.6432/0.7829/0.9513)) and a NON inferiority in terms of preventing strokes exists. CONCLUSIONS: DTA is not inferior to heparin in ECLS/ECMO therapy. Regarding all complications, stroke, thromboembolism, amputation DTA is superior.