Daily Anesthesiology Research Analysis
Analyzed 106 papers and selected 3 impactful papers.
Summary
Analyzed 106 papers and selected 3 impactful articles.
Selected Articles
1. Sodium Bicarbonate for In-Hospital Cardiac Arrest: A Randomized Clinical Trial.
In 779 analyzed adults with in-hospital cardiac arrest, sodium bicarbonate did not improve sustained ROSC compared with placebo (39% vs 37%; RR 1.05, 95% CI 0.88–1.24; P=.62). Thirty-day survival and favorable neurologic outcomes were also not significantly different, while alkalosis and hypernatremia were more common with bicarbonate.
Impact: This high-quality multicenter RCT addresses a long-standing resuscitation practice and provides definitive evidence against routine bicarbonate use during in-hospital cardiac arrest.
Clinical Implications: Do not administer sodium bicarbonate routinely during in-hospital cardiac arrest; reserve for specific indications (e.g., hyperkalemia, tricyclic overdose). Monitor for metabolic complications if used.
Key Findings
- Sustained ROSC: 39% with bicarbonate vs 37% with placebo (RR 1.05; 95% CI 0.88–1.24; P=.62).
- 30-day survival 12% vs 9.1% (RR 1.25; 95% CI 0.84–1.88) and favorable neurologic outcome 8.1% vs 5.4% (RR 1.39; 95% CI 0.82–2.34) were not significantly different.
- Metabolic adverse effects (alkalosis, hypernatremia) were more frequent with bicarbonate.
Methodological Strengths
- Multicenter, double-blind, randomized, placebo-controlled design across 21 hospitals.
- Pre-registered with ClinicalTrials.gov and rigorous outcome definitions.
Limitations
- Conducted in in-hospital cardiac arrest only; findings may not generalize to out-of-hospital settings.
- Potential underpower for survival/neurologic outcomes given wide confidence intervals.
Future Directions: Assess targeted bicarbonate use in predefined subgroups (e.g., severe hyperkalemia, specific toxicities), optimal timing/dosing strategies, and interaction with buffers during prolonged resuscitation.
IMPORTANCE: Patients with in-hospital cardiac arrest have poor outcomes. Sodium bicarbonate is commonly administered during cardiac arrest, but the effects on clinical outcomes are unknown. OBJECTIVE: To determine whether administration of sodium bicarbonate during in-hospital cardiac arrest increases the proportion of patients with return of spontaneous circulation. DESIGN, SETTING, AND PARTICIPANTS: Randomized, parallel-group, double-blind, placebo-controlled clinical trial conducted at 21 hospitals in Denmark. Participants were adults with in-hospital cardiac arrest, who received at least 1 dose of epinephrine. Patients were enrolled from February 6, 2023, to February 11, 2026, with the last 90-day follow-up conducted on May 4, 2026. Final statistical analysis was conducted on May 5, 2026. INTERVENTION: Sodium bicarbonate (up to 100 mmol) or placebo intravenously.
2. Anticholinergic Burden as a Modifiable Risk Factor in Cardiac Surgery: A Randomized Controlled Study.
In 122 older CABG patients with high baseline anticholinergic burden, immediate perioperative deprescribing significantly increased 90-day full independence (75.0% vs 41.1%) and lowered frailty compared with standard care. Anticholinergic anesthetic/analgesic use independently predicted 90-day complications.
Impact: Identifies anticholinergic burden as a modifiable perioperative risk factor and demonstrates a pragmatic intervention that improves patient-centered outcomes.
Clinical Implications: Implement perioperative medication reviews to avoid anticholinergic anesthetic and analgesic agents in older CABG patients with high anticholinergic burden. Embed deprescribing pathways into ERAS-style cardiac surgery care.
Key Findings
- Full independence at day 90 (Katz=6): 75.0% (deprescribing) vs 41.1% (standard), p<0.001.
- Lower frailty at 90 days in deprescribing group (median CFS 3 [IQR 3–3] vs 4 [IQR 3–4], p<0.001).
- Perioperative anticholinergic anesthetic/analgesic use independently predicted 90-day complications (OR 2.43; 95% CI 1.03–5.73).
Methodological Strengths
- Randomized controlled design with patient-centered primary outcomes at 90 days.
- Use of validated scales (Katz Index, Clinical Frailty Scale) and multivariable adjustment.
Limitations
- Single-center trial with modest sample size may limit generalizability.
- Blinding details not specified; potential performance bias.
Future Directions: Confirm in multicenter pragmatic RCTs, identify high-yield drug classes to target, and evaluate scalability within cardiac ERAS pathways and other major surgeries.
OBJECTIVES: This study assessed whether reducing immediate perioperative anticholinergic burden improves functional recovery in older patients undergoing coronary artery bypass grafting (CABG). DESIGN: Prospective randomized controlled study. SETTING: Single-institution tertiary care hospital. PARTICIPANTS: One hundred twenty-two patients aged ≥60 years with preoperative Anticholinergic Cognitive Burden scores ≥3. INTERVENTIONS: Patients were assigned to either standard anesthetic and/or analgesic care including anticholinergic drugs (standard group) or a deprescribing strategy avoiding perioperative anticholinergic anesthetic and analgesic drugs (deprescribing group). MEASUREMENTS AND MAIN RESULTS: Primary outcomes were functional recovery on postoperative day 90 assessed using the Katz Index and the Clinical Frailty Scale. On postoperative day 90, full independence (Katz Index score of 6) was significantly more frequent in the deprescribing group than in the standard group (75.0% v 41.1%, p < 0.001). Frailty scores were significantly lower in the deprescribing group at 90 days (median, 3 [interquartile range (IQR), 3-3] v 4 [IQR, 3-4]; p < 0.001). Multivariate logistic regression identified perioperative use of anticholinergic anesthetic and analgesic drugs as an independent predictor of 90-day total complications (odds ratio, 2.430; 95% confidence interval, 1.031-5.726; p = 0.042). Within-group analyses showed decreased frailty scores and increased Katz Index scores from baseline to day 90 in the deprescribing group (p < 0.001 for both), whereas the standard group showed increased frailty (p < 0.001) with no significant change in Katz Index scores (p = 0.317). CONCLUSIONS: In older CABG patients, immediate perioperative deprescribing of anticholinergic medications improved 90-day functional recovery trajectories and was associated with fewer cardiac and pulmonary complications. Anticholinergic burden may represent a modifiable perioperative risk factor that should be routinely addressed in surgical care pathways to optimize outcomes in older adults.
3. Clinical Prediction Models for Prognostication After Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis.
Across 39 cohorts (95,037 patients), commonly used OHCA prognostic scores showed only moderate accuracy with substantial heterogeneity (pooled AUROCs 0.75–0.88). At common thresholds, OHCA and CAHP scores had sensitivities ~65–82% and specificities ~74–90%, limiting solo use for decisions like WLST.
Impact: Provides a rigorous synthesis clarifying that popular prognostic scores for OHCA are insufficiently accurate and heterogeneous, reinforcing multimodal prognostication and caution against premature WLST.
Clinical Implications: Use OHCA/CAHP scores as adjuncts within multimodal prognostication pathways; avoid using CPMs alone to justify withdrawal of life-sustaining therapy. Emphasize external validation and local recalibration.
Key Findings
- OHCA score ≥17: pooled sensitivity 81.8% and specificity 74.2%; ≥32: sensitivity 64.9%, specificity 89.5% (low certainty).
- CAHP score ≥150: pooled sensitivity 81.3% and specificity 77.0% (moderate certainty).
- Across 11 CPMs, pooled AUROCs ranged 0.75–0.88 with substantial heterogeneity, limiting clinical utility for irreversible decisions.
Methodological Strengths
- Systematic review and meta-analysis including 39 external validation cohorts with pooled diagnostic metrics.
- Formal risk-of-bias assessment (PROBAST) and GRADE certainty ratings.
Limitations
- All included data were observational; substantial heterogeneity and potential publication bias.
- English-language restriction; follow-up windows and outcome definitions varied across cohorts.
Future Directions: Recalibrate and update CPMs across settings, integrate biomarkers/EEG/imaging, and conduct impact analyses to test whether CPM-informed pathways improve outcomes without increasing WLST-related harm.
OBJECTIVES: Summarize the prognostic performance of existing clinical prediction models (CPMs) for neuroprognostication after out-of-hospital cardiac arrest (OHCA). DATA SOURCES: We searched Medline and Embase databases from inception to June 1, 2025. STUDY SELECTION: We selected English-language studies that included adults with OHCA and evaluated a CPM for the prediction of poor functional outcome. We excluded derivation cohorts for prognostic scores and excluded models without at least two external validation cohorts. DATA EXTRACTION: Two authors performed citation screening and data extraction. Where possible, we pooled the sensitivity and specificity of poor functional outcome, and the area under the receiver operating characteristic curve (AUROC) values for each CPM. We assessed risk of bias using the Prediction model study Risk of Bias Assessment Tool, and rated the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation. DATA SYNTHESIS: We included 39 observational cohorts (95,037 patients) evaluating 11 different CPMs, with the two most common scores being the OHCA and Cardiac Arrest Hospital Prognosis (CAHP) scores. An OHCA score greater than or equal to 17 had a pooled sensitivity of 81.8% (95% CI, 65.8-91.4%) and specificity of 74.2% (95% CI, 58.8-85.3%), while a score of greater than or equal to 32 had a pooled sensitivity of 64.9% (95% CI, 44.0-81.3%) and specificity of 89.5% (95% CI, 75.9-95.8%) for poor functional outcome (low certainty). A CAHP score greater than or equal to 150 had a pooled sensitivity of 81.3% (95% CI, 77.7-84.4%) and specificity of 77.0% (95% CI, 70.6-82.4%) for poor functional outcome (moderate certainty). Pooled AUROCs across the 11 CPMs varied from 0.75 to 0.88, with substantial heterogeneity. CONCLUSIONS: CPMs for neuroprognostication after OHCA demonstrate only moderate accuracy, with substantial heterogeneity across validation cohorts. These limitations restrict their clinical utility, particularly for irreversible decisions such as withdrawal of life-sustaining therapy.