Daily Anesthesiology Research Analysis

RATIONALE: Physician Orders for Life-Sustaining Treatment (POLST) and Advance Directives (AD) aim to honor patient autonomy. However, the impact of the signatory's identity-whether the patient or a surrogate-on clinical trajectories in the intensive care unit (ICU) remains poorly characterized. OBJECTIVES: To evaluate the association between signatory identity and terminal care intensity and hospitalization costs among adult patients in the ICU. METHODS: This nationwide population-based cohort study utilized the South Korean National Health Insurance Service database, including 1,189,042 adult ICU admissions between 2020 and 2023. Statistical analyses employed high-dimensional fixed-effects models to account for institutional variability across 417 hospitals. RESULTS: Among 1,189,042 patients, surrogate-determined POLST (SD-POLST) was more than three times as prevalent as patient-determined POLST (PD-POLST). Among 90-day decedents, PD-POLST was associated with significantly reduced odds of invasive terminal care (OR, 0.43; 95% CI, 0.43-0.54). Conversely, SD-POLST more than doubled the odds (OR, 2.16; 95% CI, 1.98-2.35). Notably, even patients with proactive ADs experienced increased care intensity once a surrogate signed the final order (OR, 1.69; 95% CI, 1.51-1.89), indicating a phenomenon of "AD erosion." SD-POLST was also associated with significantly higher daily hospitalization costs (cost ratio, 1.04; 95% CI, 1.02-1.06) compared with no documentation. CONCLUSION: The clinical efficacy of POLST in limiting non-beneficial care depends fundamentally on the signatory. Surrogate-led decisions were associated with paradoxically higher care intensity and costs, potentially overriding prior patient wishes. These findings highlight the critical importance of early, patient-led discussions to ensure goal-concordant end-of-life care in the ICU.

This prospective study compared the Marsh and Schnider pharmacokinetic models for propofol target-controlled infusion (TCI) during anesthetic induction in obese patients undergoing elective cardiac surgery. A total of 118 patients were randomly assigned to either the Marsh or Schnider group (n = 59 each). The primary outcome was the performance error (ΔC = measured minus predicted plasma concentration) during and after TCI. Secondary outcomes included hemodynamic pharmacokinetic-pharmacodynamic (PK-PD) model, anesthetic depth (BIS), cardiac function (LVEF, SV), electrocardiographic PK-PD model (QTc, QTcd), and recovery profiles. While no significant differences in ΔC were observed during TCI, the Marsh model demonstrated significantly lower ΔC at all time points after TCI cessation (p < 0.05). Compared to the Schnider group, the Marsh group also showed higher BIS values, better preserved LVEF and SV, shorter QTc/QTcd intervals, reduced propofol requirements, and shorter recovery times (all p < 0.05). In conclusion, under the conditions of this study, in which propofol TCI was configured using total body weight for the Marsh model and lean body weight for the Schnider model, the Marsh model provided more accurate plasma concentration control, better hemodynamic stability, and improved recovery profiles compared with the Schnider model for anesthetic induction in obese cardiac surgery patients.

BACKGROUND: Although functional endoscopic sinus surgery (FESS) constitutes a standard treatment for the management of chronic rhinosinusitis, intraoperative bleeding poses a considerable challenge by impairing visibility and increasing complication risks. Controlled hypotension is a widely employed technique to mitigate bleeding; however, excessive blood pressure reduction may compromise systemic perfusion and predispose to organ ischemia. OBJECTIVES: Due to the scarcity of literature evaluating the safety of controlled hypotension in FESS, we aimed to systematically review current evidence on the risks and potential complications of this technique, with an emphasis on systemic adverse events (hemodynamic instability, neurological impairment, and renal dysfunction). METHODS: The PubMed, Embase, and Cochrane databases were searched for English-language original articles published until October 1, 2025. Studies were considered eligible if they reported mean arterial pressure (MAP) values achieved and evaluated systemic complications associated with controlled hypotension during FESS. RESULTS: A total of 32 articles were found eligible and included in the further analysis. Most protocols aimed for a MAP of 50-70 mmHg, primarily using dexmedetomidine, propofol, and remifentanil. Only 8 of the 32 studies utilized advanced intraoperative monitoring (e.g., near-infrared spectroscopy [NIRS], transcranial Doppler [TCD], and non-invasive cardiac output monitoring [NICOM]). The most frequent minor complication was postoperative nausea and vomiting (in 2-62% of cases). Significant hemodynamic disturbances included intraoperative bradycardia and severe hypotension (MAP < 50 mmHg), requiring pharmacological intervention. While no permanent neurological deficits were reported, intraoperative cerebral desaturation was observed in 2 studies. The follow-up observation rarely extended beyond the post-anesthesia care unit and did not include a structured assessment of cerebral and renal function. CONCLUSIONS: Subclinical complications of controlled hypotension during FESS may be overlooked without advanced intraoperative monitoring, postoperative biomarker surveillance, and a long-term follow-up period. The application of a uniform MAP target of 50-70 mmHg may be insufficient in high-risk patients. The development of personalized hemodynamic management strategies and enhanced perfusion-monitoring protocols is required to reduce the risk of occult organ ischemia and to define safe limits for controlled hypotension in FESS.