Daily Anesthesiology Research Analysis

BACKGROUND: We performed a systematic review and meta-analysis of randomised controlled trials (RCTs) to determine whether individualised intraoperative blood pressure (BP) management improves postoperative outcomes in patients having noncardiac surgery compared with routine BP management. METHODS: A comprehensive literature search was performed across PubMed, Scopus, Web of Science, and Embase for relevant RCTs. The primary outcome was the incidence of postoperative acute kidney injury (AKI). We performed frequentist (random-effects model with Knapp-Hartung adjustment) and Bayesian meta-analyses. RESULTS: Ten RCTs (n=5842 patients) were included. Although individualised, compared with routine, intraoperative BP management resulted in significantly higher intraoperative BP (reflected by a reduction in the area under a mean arterial pressure (MAP) of 65 mm Hg; mean difference -44.5 mm Hg × min, 95% confidence interval [CI] -58.5 to -30.4, P=0.0005), it did not reduce the incidence of AKI (risk ratio [RR] 0.83, 95% CI 0.65-1.07, P=0.13), 30-day mortality (RR 0.78, 95% CI 0.35-1.75, P=0.44), or myocardial injury (RR 1.11, 95% CI 0.92-1.35, P=0.14). A significant reduction in postoperative delirium was observed (RR 0.46, 95% CI 0.25-0.83, P=0.02). Bayesian analysis indicated a 91% probability of any degree of AKI protection (RR<1); however, the probability of this benefit reaching a clinically meaningful threshold (RR<0.8) was low (39%). CONCLUSIONS: Compared with routine intraoperative BP management (typically targeting MAP ≥60-65 mm Hg), individualised intraoperative BP management resulted in higher intraoperative BP but did not significantly reduce postoperative AKI. Individualised intraoperative BP management might decrease the risk of postoperative delirium. SYSTEMATIC REVIEW PROTOCOL: CRD420251186093.

PURPOSE: Thoracic paravertebral block (TPVB) provides effective analgesia for video-assisted thoracoscopic surgery (VATS). However, even when pain is well-controlled by TPVB, female patients remain at high risk for postoperative nausea and vomiting (PONV) and sleep disturbances because of non-analgesic factors, such as hormonal and central emetic pathways. We investigated whether adding a two-stage diphenhydramine regimen to TPVB-based multimodal analgesia improves early recovery quality. METHODS: In this prospective, randomized, double-blind, placebo-controlled trial, 80 women (ASA I-III) scheduled for elective VATS pulmonary resection were randomized to receive a two-stage diphenhydramine regimen (0.2 mg/kg bolus at chest closure followed by 0.5 mg/kg via postoperative patient-controlled intravenous analgesia [PCIA]) or placebo (normal saline). All patients received standardized TPVB with 20 mL 0.4% ropivacaine, PCIA with sufentanil/ondansetron, and intravenous dexamethasone 10 mg. The primary outcome was the 24-h Quality of Recovery-15 (QoR-15) score. Secondary outcomes included sleep quality, PONV incidence, pain scores, rescue medication requirements, and adverse events. RESULTS: The diphenhydramine group exhibited a significantly higher median 24 h QoR-15 score (127 [IQR 121-134.75] vs. placebo 119.5 [IQR 108.25-130.75], P=0.033). This group also demonstrated markedly better sleep quality (lower Athens Insomnia Scale scores at 24 and 48 h, P<0.05) and a significantly reduced incidence of vomiting (10% vs. 40%, P=0.004). Overall PONV rates and other secondary outcomes were comparable, with no difference in adverse events. CONCLUSIONS: Adding a two-stage diphenhydramine regimen to TPVB-based multimodal analgesia significantly improves early recovery quality, enhances postoperative sleep, and reduces vomiting in women after VATS, without increasing adverse events. CLINICAL TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR2500097837).

OBJECTIVES: To develop and validate, a real-time algorithm to individualize unfractionated heparin (UFH) dosing based on activated clotting time (ACT) dynamics in cardiac procedures with or without cardiopulmonary bypass (CPB). DESIGN: A retrospective cohort study. SETTING: University hospitals; multiinstitutional for external validation. PARTICIPANTS: Adult patients undergoing cardiac surgery with or without CPB. INTERVENTIONS: Development of a pharmacodynamic model of ACT response to UFH incorporating CPB-adjusted scaling. Based on this model, an individualized dosing algorithm was implemented to enable a real-time online decision-support tool for clinical use. MEASUREMENTS AND MAIN RESULTS: The model was developed using data from 446 patients (2,534 ACT measurements) and externally validated in 105 patients from an independent center. Clinical implementation was retrospectively evaluated in 83 patients and compared with 83 matched historical controls. The model demonstrated strong predictive performance, with decreasing bias and mean absolute error as additional ACT measurements were incorporated. Individualized dosing achieved ACT values closer to target and significantly reduced ACT variability compared with controls (variance ratio = 2.3; p < 0.001), while using lower UFH doses without compromising anticoagulation. CONCLUSIONS: The real-time individualized UFH dosing algorithm was associated with improved control of ACT values and reduced variability during cardiac procedures in this retrospective analysis. These findings suggest that Bayesian-guided dosing may enhance the precision of anticoagulation management under routine clinical conditions. However, given the study design, device-specific ACT measurements, and limited clinical outcome data, these results should be interpreted as preliminary. Prospective, adequately powered studies are required to confirm clinical benefit, safety, and broader applicability.