Daily Anesthesiology Research Analysis
Analyzed 121 papers and selected 3 impactful papers.
Summary
Today's top anesthesiology-relevant papers include: a randomized trial showing sugammadex more stably maintains cerebral perfusion during emergence from carotid endarterectomy; a Cochrane systematic review suggesting TEG/ROTEM-guided transfusion may reduce mortality and blood product use (with uncertainty, mainly in cardiac surgery); and a triple‑blinded dose‑finding study demonstrating preterm cesarean deliveries require substantially higher oxytocin infusion to achieve adequate uterine tone, supported by receptor expression data.
Research Themes
- Neuromuscular blockade reversal and cerebral perfusion during high-risk vascular surgery
- Viscoelastic testing (TEG/ROTEM) to guide hemostatic therapy in perioperative bleeding
- Gestational differences in oxytocin pharmacodynamics for cesarean delivery uterine atony prevention
Selected Articles
1. Sugammadex Vs. Neostigmine for Cerebral Perfusion During Emergence From General Anesthesia in Patients Undergoing Carotid Endarterectomy: A Double-Blind Randomized Controlled Trial.
In a randomized controlled trial of CEA patients, sugammadex reduced the area-under-curve of middle cerebral artery velocity relative to baseline during emergence versus neostigmine, with faster awakening/extubation and fewer pulmonary complications. Mediation analysis suggested shorter extubation partially explained improved cerebral flow stability; MCAV%S predicted hyperperfusion.
Impact: Provides randomized evidence that choice of reversal agent can influence cerebral perfusion stability in high-risk vascular surgery, extending sugammadex benefits beyond speed of reversal to potential neuroprotection.
Clinical Implications: Consider preferential use of sugammadex for neuromuscular reversal in CEA and similar cerebrovascularly vulnerable contexts to stabilize cerebral perfusion during emergence and possibly reduce complications; integrate cerebral flow monitoring (e.g., TCD) into protocols.
Key Findings
- Sugammadex lowered emergence MCAV%S AUC versus neostigmine (24,600 vs 31,575; p=0.044), persisting after adjustment.
- Faster eye-opening and extubation with sugammadex, alongside lower hypoxemia incidence and pulmonary complication scores.
- Extubation time partially mediated the effect on MCAV%S; MCAV%S showed good ROC performance to predict cerebral hyperperfusion.
Methodological Strengths
- Prospective randomized controlled design with prespecified physiologic primary endpoint (MCAV%S AUC).
- Use of mediation and multivariable analyses to probe mechanisms and adjust confounding.
Limitations
- Single-center study with modest sample size (n=82), limiting generalizability.
- Primary outcomes were surrogate physiologic measures; hard neurologic endpoints and long-term outcomes were limited to early (≤48 h) complications.
Future Directions: Multicenter, adequately powered RCTs assessing clinical endpoints (e.g., CHS incidence, stroke, neurocognition) and cost-effectiveness of sugammadex versus neostigmine in carotid and other neurovascular surgeries.
BACKGROUND: Carotid endarterectomy (CEA) is the standard treatment for carotid stenosis, but has the risk of cerebral hyperperfusion syndrome (CHS). Postoperative residual neuromuscular blockade can trigger cerebral hyperperfusion (CH), and the effects of neostigmine and sugammadex on cerebral perfusion during CEA are unclear. OBJECTIVE: This study aimed to compare the efficacy of neostigmine combined with atropine and sugammadex in reversing neuromuscular blockade in CEA patients under general anesthesia and evaluate the superiority of sugammadex in maintaining normal cerebral perfusion during anesthesia emergence. METHODS: A single-center, prospective, randomized controlled study was carried out and registered on the Chinese Clinical Trial Registry website (ChiCTR2300078579). Between December 2023 and June 2024, 90 patients were recruited. After exclusions, 82 patients were randomly assigned to the sugammadex group or the neostigmine group at a 1:1 ratio. The primary outcome was the difference in the area under the curve of the percentage of middle cerebral artery velocity relative to baseline (MCAV% S) during emergence. Secondary outcomes included multiple hemodynamic and clinical parameters, as well as pulmonary and CH-related complications within 48 h post-operation. Mediation analysis, ROC analysis, and multivariate linear regression analysis were used to illustrate the differences in MCAV%S between the two groups and subsequent analysis. RESULTS: The MCAV% S in the sugammadex group was significantly lower than in the neostigmine group (24,600 [14,940-38,040] vs. 31,575 [24,210-50,040], p = 0.044), and this difference persisted after adjusting for variables (Estimate (95% CI): -10,896 [-21,387 ~ -405]; p = 0.042). The sugammadex group had shorter eye-opening and extubation times, and a lower incidence of hypoxemia and overall pulmonary complication score. Mediation analysis showed that extubation time mediated part of the effect on MCAV% S, and the ROC analysis indicated good predictive performance of MCAV% S for CH. CONCLUSION: In CEA patients, sugammadex is more advantageous than neostigmine in reversing neuromuscular blockade during emergence, as it shortens extubation time, reduces excessive cerebral blood flow, and potentially lowers the incidence of postoperative complications.
2. Thromboelastography (TEG) or thromboelastometry (ROTEM) to monitor haemostatic treatment versus usual care in adults or children with bleeding.
This Cochrane review of 35 RCTs (n=3,096) suggests that TEG/ROTEM-guided transfusion algorithms may reduce mortality, bleeding, reoperation, and use of fresh frozen plasma and platelets compared with standard care. Evidence certainty remains low-to-moderate and largely derives from adult elective cardiac surgery.
Impact: Synthesizes randomized evidence across perioperative settings to inform hemostatic management—an area central to anesthesiology—highlighting potential mortality benefit while transparently addressing uncertainty.
Clinical Implications: Adopting structured, TEG/ROTEM-guided transfusion algorithms can be considered—especially in cardiac surgery—while institutions should evaluate local feasibility, training, and quality assurance given heterogeneity and evidence uncertainty.
Key Findings
- Across 35 RCTs (n=3,096), TEG/ROTEM-guided algorithms may reduce all-cause mortality (RR≈0.76) versus standard care.
- Guided strategies were associated with lower bleeding, reduced use of FFP and platelets, and fewer surgical re-interventions.
- Evidence is primarily from elective cardiac surgery and judged uncertain; calls for larger, low-bias RCTs in diverse settings.
Methodological Strengths
- Cochrane methodology with comprehensive search, duplicate screening, and risk of bias assessment.
- Use of Trial Sequential Analysis to assess random error and robust sensitivity/subgroup analyses.
Limitations
- Heterogeneity in populations, algorithms, and comparators; many trials in cardiac surgery limit generalizability.
- Uncertainty in effect estimates and variable reporting of patient-centered outcomes beyond hospitalization.
Future Directions: Well-powered, low-bias RCTs of TEG/ROTEM-guided care across trauma, obstetrics, pediatrics, sepsis, and high-risk surgery evaluating long-term survival, adverse events, and cost-effectiveness.
BACKGROUND: Severe bleeding and coagulopathy are serious clinical conditions that are associated with high mortality. Thromboelastography (TEG) and thromboelastometry (ROTEM) are increasingly used to guide transfusion strategy, but their roles remain disputed. This is an update of a review that was first published in 2011 and updated in January 2016. OBJECTIVES: The objective was to evaluate the benefits and harms of TEG-/ROTEM-guided transfusion strategies for bleeding in adults and children by comparing TEG-ROTEM-guided transfusion with standard treatment. SEARCH METHODS: In this updated review, we identified randomised controlled trials (RCTs) from the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE(R) ALL; Embase; Web of Science Core Collection and Biosis Previews via Clarivate; CINAHL EBSCO; and the WHO Global Index Medicus incl. LILACS (from 2015 up to 5 January 2025). We searched for ongoing clinical trials and unpublished studies in the following registries during the aforementioned period: ISRCTN, ClinicalTrials.gov, CentreWatch, and UMIN-CTR. We contacted trial authors, authors of previous reviews, and manufacturers in the field. The original searches were run in October 2010 and January 2016. SELECTION CRITERIA: We included all RCTs, irrespective of blinding or language, that compared transfusion guided by TEG or ROTEM to transfusion guided by clinical judgement, guided by standard laboratory tests, or a combination. We also included interventional algorithms including both TEG and ROTEM in combination with standard laboratory tests or other devices. The primary analysis included trials on TEG or ROTEM versus any comparator. DATA COLLECTION AND ANALYSIS: Two review authors independently abstracted data; we resolved any disagreements by discussion. We presented pooled estimates of the intervention effects on dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). Due to skewed data, meta-analysis was not provided for continuous outcome data. Our primary outcome measure was all-cause mortality. We performed subgroup and sensitivity analyses to assess the effect of a TEG- or ROTEM-guided algorithm in adults and children on various clinical and physiological outcomes. We evaluated potential bias by examining trial methodological components using the Cochrane Risk of Bias 1 and assessed the risk of random error through Trial Sequential Analysis (TSA). MAIN RESULTS: This systematic review included 35 randomised trials (n = 3096), with most involving patients undergoing elective cardiac surgery. Hence, 18 trials and 1603 participants were added since the previous update of this review. TEG-/ROTEM-guided transfusion algorithms may be associated with a reduction in mortality (RR 0.76, 95% CI 0.63 to 0.92; 19 trials; 1865 participants, I AUTHORS' CONCLUSIONS: TEG-/ROTEM-guided transfusion algorithms may reduce the risk of mortality, bleeding volume, and the need for fresh frozen plasma, platelets, and surgical re-intervention, but the evidence is very uncertain. Furthermore, the results were primarily based on the adult population undergoing elective cardiac surgery. Hence, the conclusion remains unchanged from the previous update of this review. There is a need for large, low risk of bias randomised controlled trials evaluating TEG/ROTEM across diverse clinical settings, including paediatric and neonatal populations, sepsis, trauma, obstetrics, and high-risk surgical and critically ill cohorts requiring major transfusion. Future studies should be adequately powered and prioritise patient-centred outcomes such as long-term survival, adverse events, cost-effectiveness, and the role of TEG/ROTEM in coagulopathy and severe haemorrhage.
3. Minimum Effective Dose of Prophylactic Oxytocin Infusion During Cesarean Delivery in Preterm and Term Pregnancy: A Sequential Allocation Dose Finding Study.
In triple-blinded sequential dose-finding (n=60), the oxytocin infusion ED90 to prevent intraoperative uterine atony was ~1.5× higher in preterm vs term cesarean delivery (25.7 vs 16.2 IU·h−1). Immunohistochemistry confirmed lower myometrial oxytocin receptor expression in preterm, aligning with higher dosing needs; oxytocin-associated hypotension was more frequent in preterm.
Impact: Provides mechanistically supported, gestation-specific dosing data that can refine oxytocin infusion protocols during cesarean delivery—a ubiquitous anesthetic context with high stakes for hemorrhage prevention.
Clinical Implications: For preterm cesarean deliveries, anticipate higher oxytocin infusion rates to achieve satisfactory uterine tone, while proactively mitigating hypotension (e.g., vasopressor support, incremental dosing) and considering patient-specific risks.
Key Findings
- Oxytocin ED90 was 25.7 IU·h−1 (95% CI 16.4–35.1) in preterm vs 16.2 IU·h−1 (95% CI 14.8–17.7) in term cesarean deliveries.
- Term pregnancies exhibited higher myometrial oxytocin receptor expression by IHC (P=0.040), consistent with lower dosing needs.
- Preterm group had more oxytocin-associated hypotension (50% vs 13%; P=0.002) and higher intraoperative oxytocin use.
Methodological Strengths
- Triple-blinded, biased-coin sequential allocation dose-finding design tailored to estimate ED90.
- Biological validation via immunohistochemical receptor quantification linking pharmacodynamics to dosing.
Limitations
- Small, single-center sample (n=60) with surgeon palpation method for uterine tone, which may introduce subjectivity.
- Findings focus on infusion ED90 under spinal anesthesia and may not generalize to all anesthetic techniques or populations.
Future Directions: Larger multicenter trials to refine gestation-specific dosing tables, integrate hemodynamic safety protocols, and compare infusion versus bolus-plus-infusion strategies across anesthetic techniques.
BACKGROUND: There is a paucity of uterine oxytocin receptors during preterm gestation. Whether this affects the requirement of oxytocin dose for uterine contraction in patients with preterm gestation is not researched. We compared effective dose in 90% of target population (ED90) of oxytocin infusion for satisfactory uterine tone during cesarean delivery in patients with preterm and term pregnancy. METHODS: This biased coin sequential allocation, dose finding study, with triple blinding to dose allocation included nonlaboring women >18 years posted for cesarean delivery under spinal block, into either term or preterm group (n = 30 each; completed or <37-week gestation, respectively). Oxytocin infusion was initiated at 13 IU·h-1 in the first patient in both groups. Dose in subsequent cases was determined by response to oxytocin in previous patient of a particular group (dosing interval = 2 IU·h-1). Uterine tone was assessed using the one-finger palpation method by the surgeon. Myometrial oxytocin receptor expression was also evaluated on tissue obtained during surgery, using immunohistochemistry (IHC). RESULTS: The ED90 of oxytocin infusion to prevent intraoperative uterine atony was 1.5 times greater in the preterm group (25.7 IU·h-1 [95% confidence interval {CI}, 16.4-35.1]) as compared to the term group (16.2 IU·h-1 [95% CI, 14.8-17.7]). Intraoperative oxytocin amount was significantly greater (14.3 [11.7-17.5] vs 12.8 [10.4-14.7] IU; P = .048), and the need of additional uterotonic was clinically higher (16% vs 10%; effect size = 0.5 [95% CI, 0.1-2.5]; P = .448) for the preterm group. IHC showed increased oxytocin receptor expression for term versus preterm group (P = .040). Incidence of oxytocin-associated hypotension was greater for preterm group (50% vs 13%; P = .002). CONCLUSIONS: During cesarean delivery, oxytocin requirement is almost 1.5 times greater for preterm as compared to term pregnancy. This was supported by decreased expression of the myometrial oxytocin receptor upon IHC.