Daily Anesthesiology Research Analysis

PURPOSE: Critically ill patients with acute leukemia often require an intensive care unit (ICU) admission. As major therapeutic advances have been made during the last decades, the aim of this study was to assess temporal trends in ICU mortality, and identify prognostic factors to inform clinician decision-making. METHODS: We conducted an individual participant data meta-analysis of studies including adults with acute leukemia admitted to the ICU. Patients with a history of allogeneic hematopoietic stem cell transplantation were excluded. Mixed-effects logistic regression models, accounting for center of ICU admission as a random variable, evaluated factors associated with ICU mortality, with particular focus on year of ICU admission, age (> 65 years) and invasive mechanical ventilation. RESULTS: A total of 2003 patients from 55 ICUs across 19 countries were included (median age 58 years [IQR 44-67]; 72% acute myeloid leukemia [AML]; 64% admitted during induction chemotherapy). Invasive mechanical ventilation, vasopressors, and renal replacement therapy were required in 55%, 57%, and 21% of patients, respectively. Crude ICU mortality was 45% overall and 66% among ventilated patients. Age > 65 years (odds ratio (OR) 1.98 [95% CI 1.49-2.64]), diagnosis of AML (OR 1.70 [1.23-2.34]), admission during diagnosis or induction chemotherapy (OR 1.50 [1.08-2.07]), relapsed or refractory disease (OR 2.08 [1.36-3.21]), the need for mechanical ventilation (OR 6.46 [4.84-8.63]), and the need for other life-sustaining therapies (OR 2.21 [1.62-3.02]) were associated with increased ICU mortality. Year of ICU admission was associated with improved survival only among ventilated patients (OR per additional year 0.93 [0.93-0.93]). CONCLUSIONS: In this large international individual participant meta-analysis, survival of critically ill patients with acute leukemia improved over time, particularly among those requiring mechanical ventilation. Age and the need for mechanical ventilation and other life-sustaining therapies remain strong, independent predictors of ICU mortality. Future work should integrate frailty and functional assessments to refine prognostic stratification and guide treatment intensity in this complex population. TRIAL REGISTRATION: The protocol was registered in PROSPERO (CRD420251046286).

BACKGROUND: Single-injection erector spinae plane blocks (ESPB) provide analgesia following percutaneous nephrolithotomy (PCNL) but are limited in their duration. A continuous ESPB involving local anesthetic administered via a perineural catheter may extend analgesia duration. We hypothesized that adding a continuous ESPB to a single-injection ESPB following outpatient PCNL would decrease pain severity and/or opioid consumption over the first 2 postoperative days (dual primary outcomes). METHODS: Preoperatively, adults undergoing PCNL had an ultrasound-guided perineural catheter inserted at the 8th transverse process following saline injection. Bupivacaine 0.25% with epinephrine (20 mL) was manually injected via the catheter for all participants who were subsequently randomly allocated to one of two postoperative treatments: ACTIVE with bupivacaine 0.25% or PLACEBO with normal saline. An automatic intermittent bolus of 21 mL was delivered every 4 hours using a portable infusion pump for approximately 57 h. RESULTS: During the first 2 postoperative days, the median [interquartile range] average daily pain intensity as measured with the numeric rating scale for ACTIVE (n=25) was 3.5 [2.0, 4.5] compared with 3.0 [1.3, 4.5] for PLACEBO (n=25; estimated difference 0.25, 95% CI -1.0 to 1.5; p=0.538). Cumulative oxycodone consumption during this same period was 10 [0, 25] mg for ACTIVE versus 15 [0, 30] mg for PLACEBO (estimated difference 0, 95% CI -15 to 5; p=0.358). During this period, the maximum daily pain for ACTIVE was 7.0 [4.3, 8.0] compared with 6.5 [5.5, 8.0] for PLACEBO (p=0.754). Sleep disturbances the second night were 0 [0, 1] for both groups (p=0.423). During the day after surgery, pain's interference with physical and emotional functioning was 10 [0, 33] for ACTIVE and 8 [23, 48] for PLACEBO as measured with the Brief Pain Inventory (p=0.587). CONCLUSIONS: This investigation failed to identify benefits of adding a continuous ESPB to a single-injection ESPB following PCNL.

BACKGROUND: Tranexamic acid (TXA) reduces perioperative blood loss, but comparative effectiveness and safety across administration routes remain uncertain. We evaluated topical, intravenous [IV], and oral TXA in unilateral total hip and knee arthroplasty. METHODS: Using Taiwan's national health insurance database (2012-2021), we identified patients undergoing unilateral arthroplasty and evaluated perioperative TXA use, red blood cell transfusion, and adverse events within 60 days after discharge. Conditional logistic regression and six propensity-score-matched comparisons were conducted: topical vs none, IV vs none, oral vs none, topical vs IV, topical+ 1.0g IV vs topical alone, and IV+ 1.0g topical vs IV alone. RESULTS: Compared with no TXA, all routes were associated with lower transfusion risk (topical: RR 0.45, 95%CI 0.41-0.48, p <0.001; IV: RR 0.80, 95%CI 0.79-0.84, p <0.001; oral: RR 0.82, 95%CI0.73-0.92, p=0.007). Topical and IV TXA were associated with similar risk (RR 1.09, 95%CI:0.96-1.24, p>0.999), and the combined use was not associated with a different risk compared with either route alone. Topical TXA was associated with the greatest reduction in predicted transfusion risk at low dose (- 3,087 per 10,000 [-2,886, -3,276], 0→3.0g). Overall, TXA use was not associated with increased venous thromboembolism (VTE), infections, or wound complications. A higher VTE incidence was observed with topical TXA in patients with prior vascular disease without pharmacological prophylaxis, but this was not significant after adjustment for confounders. TXA was not associated with renal injury overall, but high-dose IV (>3.0 g) or oral (>8.0 g) TXA increased predicted risk (~10%) in patients with preexisting renal disease. CONCLUSION: TXA use was associated with substantial transfusion reduction without an overall increase in adverse events. No administration route or combination proved superior. Caution is warranted with higher-dose IV or oral TXA in patients with renal disease, and the association between topical TXA and VTE in high-risk patients merits further investigation.