Daily Anesthesiology Research Analysis

BACKGROUND: Cardiac surgery performed through a midline chest incision (median sternotomy) is associated with substantial postoperative pain and opioid use, the latter of which remains the dominant modality of analgesia. Contemporary international guidelines prioritise opioid-sparing, multimodal strategies; however, robust randomised evidence to support specific opioid-sparing analgesic approaches in cardiac surgery is lacking. METHODS: EPOCH CardioLink-10 was a pan-Canadian, multicentre, randomised, double-blind, placebo-controlled trial in adults undergoing cardiac surgery via median sternotomy. Participants were assigned to receive bilateral superficial parasternal intercostal plane (SPIP) blocks with either 0.2% ropivacaine or placebo (0.9% sodium chloride), delivered via indwelling catheters. Study interventions were delivered at a basal infusion rate (0.1-1 mL/h) after a 20 mL bolus post-insertion. Bolus dosing of 5 mL every 3-4 h was continued for 48 h. In the ropivacaine arm, this resulted in a maximum total ropivacaine dose of 592 mg over the infusion period. The primary outcome was cumulative opioid consumption over 72 h following catheter insertion, expressed in morphine milligram equivalents (MMEs). Secondary outcomes included subjective pain scores, cumulative use of opioid to discharge, rates of delirium, and participant-reported Quality of Recovery-15 score (ClinicalTrials.govNCT06028126). FINDINGS: Between Aug 16, 2023, and Dec 22, 2025, 650 patients were screened, and 318 included in the modified intention-to-treat population (164 in the ropivacaine group, 154 in the placebo group). Median age was 67 years (IQR 61-72), 72 (23%) participants were female, 178 (56%) were White, and 69 (22%) were South Asian. Over 72 h, ropivacaine reduced opioid consumption compared with placebo (least-squares mean difference -20.7 MMEs [95% CI -39.0 to -2.3]; p = 0.027). Pain scores and other secondary outcomes were similar between groups. There were no serious block-related complications and there was no pre-specified analysis of adverse events. INTERPRETATION: The findings of this multicentre, randomised trial suggest that bilateral SPIP blockade with ropivacaine may be a pragmatic option to manage sternotomy pain with lower opioid consumption post-cardiac surgery. FUNDING: Grants from the Canadian Institutes of Health Research (CIHR) [...]

BACKGROUND: A previous study has shown that tidal volume >5 mL/kg, conjugate gaze, facial grimace, purposeful movement, and eye opening are predictive of emergence and extubation readiness in children anesthetized primarily with inhalational agents. We hypothesize that having any three of the "Big Five" criteria above will be similarly predictive of extubation success even if upper respiratory symptoms are present. METHODS: Following verbal consent, 756 patients ≤9 years of age were extubated awake. A parental questionnaire was performed preoperatively to assess upper respiratory symptoms and risk factors for respiratory adverse events. Based on this questionnaire, patients were assigned to either the non-upper respiratory infection symptom cohort or the upper respiratory infection symptom cohort. The presence or absence of the "Big Five" and other routine extubation criteria were recorded at extubation. Patients were included in the primary analysis only if they achieved ≥3 of the "Big Five" at the time of extubation. Awake extubations were graded as successful, intervention required, or major intervention required, according to a standard rubric. Intervention required and major intervention required were combined as a single outcome for the primary analysis. The positive predictive value of successful extubation was compared between the two cohorts using an equivalence analysis. The clinical equivalence margin was set at <5%. RESULTS: The positive predictive value of successful extubation with ≥3 of "Big Five" criteria in the non-upper respiratory infection symptom cohort was 94.7%[95%CI 92.5-97.0%] and 93.9%[95%CI 91.5%-96.3%] in the upper respiratory infection symptom cohort. The effect size and 95% confidence interval was 0.8%(95%CI -2.6%-4.2%). This was below the clinical equivalence margin of 5%. CONCLUSIONS: The presence of three or more of the "Big Five" criteria appears to be equivalently predictive of successful awake extubation in patients with upper respiratory symptoms when compared to patients with no upper respiratory symptoms.

BACKGROUND: Rapid Sequence Induction (RSI) is commonly performed in the operating room to quickly secure the airway and minimize aspiration risk, especially in patients undergoing abdominal surgery. Current practice patterns of medications and RSI techniques used by anesthesiologists are not well-described. METHODS: This observational cohort study utilized the Multicenter Perioperative Outcomes Group database to evaluate RSI practices on adult patients undergoing abdominal surgery from 2015 to 2022. The primary aim was to describe modern RSI practices. We evaluated peri-induction medication use and intubation techniques. We hypothesized that over time, rocuronium would become the most utilized agent. Additionally, we investigated how the choice of neuromuscular blocking agent (NMB) affected outcomes using mixed-effects models and targeted maximum likelihood estimation. The primary endpoint was 30-day mortality. Secondary endpoints included post-induction hypoxia, pulmonary complications, and acute kidney injury (AKI). RESULTS: Across 13 institutions and 82,772 cases, 9,352 (11.3%) had a documented RSI. The most common NMB was succinylcholine (70.5%). However, the use of succinylcholine significantly decreased over the study period (85.4% of RSI cases in 2015; 37.3% in 2022, p < 0.0001), replaced by rocuronium. Patients usually received coadministration of multiple sedatives. Video laryngoscopy was more frequently used (16.2% of RSI vs 8.0% of non-RSI cases, p<0.0001). Rocuronium was not associated with a different risk of mortality (relative risk 0.85; 95% confidence interval 0.67 - 1.09), hypoxia (1.04; 0.61-1.77), pulmonary complications (0.93; 0.81-1.06), or AKI (1.05; 0.84-1.31) as compared to succinylcholine. CONCLUSION: Across institutions in the United States, rocuronium has been increasingly used for RSI, eventually overtaking succinylcholine. Rocuronium use was not associated with a different risk of mortality, hypoxia, pulmonary complications, or AKI.