Daily Anesthesiology Research Analysis
Analyzed 201 papers and selected 3 impactful papers.
Summary
Analyzed 201 papers and selected 3 impactful articles.
Selected Articles
1. Multimodal Prehabilitation for Older Adults Undergoing Spinal Fusion : A Randomized Clinical Trial.
In a multicenter assessor-blinded randomized trial of patients ≥75 undergoing elective spinal fusion, adding a 4-week multimodal prehabilitation to ERAS reduced 90-day complications (RR 0.80; risk difference −18%). The program integrated Vivifrail exercise, nutrition optimization, and psychological support.
Impact: Provides high-level evidence that structured prehabilitation meaningfully reduces postoperative morbidity in very elderly spine patients, a high-risk and growing population.
Clinical Implications: Centers caring for very elderly spine patients should consider implementing resource-feasible multimodal prehabilitation within ERAS pathways to reduce complications; local resources and workflows must be planned.
Key Findings
- PREERAS reduced any 90-day postoperative complication versus ERAS alone (RR 0.80; 95% CI 0.67–0.95).
- Absolute risk difference in complications was −18% (95% CI −27% to −9%).
- Intervention combined supervised Vivifrail exercise, nutrition optimization, and psychological support over 4 weeks.
Methodological Strengths
- Multicenter, assessor-blinded randomized controlled design with trial registration
- Clinically meaningful primary endpoint (90-day complications) and standardized grading (Clavien-Dindo)
Limitations
- Open-label to participants and clinicians, potential performance bias
- Generalizability may be limited due to system-level differences (longer hospital stays in study setting)
Future Directions: Cost-effectiveness analyses, implementation studies across diverse health systems, and identification of subgroups with greatest benefit.
BACKGROUND: Older adults often have impaired physiologic reserve and are at higher risk for postoperative complications after spinal fusion surgery. OBJECTIVE: To evaluate the efficacy of multimodal prehabilitation plus Enhanced Recovery After Surgery (PREERAS) versus ERAS alone on 90-day postoperative complications in older adults undergoing elective spinal fusion. DESIGN: Multicenter, open-label, assessor-blinded, 1:1 parallel-group randomized controlled trial. (ClinicalTrials.gov: NCT06140797). SETTING: 3 tertiary hospitals in China. PARTICIPANTS: Adults aged 75 years or older undergoing elective spinal fusion surgery between May 2024 and May 2025. INTERVENTION: Participants were randomly assigned to receive either preoperative Vivifrail-based, multimodal PREERAS (PREERAS group) or ERAS alone (ERAS group). The 4-week prehabilitation program integrated supervised group sessions, Vivifrail multicomponent exercise, nutritional optimization, and psychological interventions. MEASUREMENTS: The primary outcome was the occurrence of any postoperative complication within 90 days of surgery, recorded and graded per the Clavien-Dindo classification system. RESULTS: A total of 312 patients were assessed for eligibility, with 164 randomly assigned. Of the 159 patients included in the final analysis (mean age, 78.7 years; 59% women), 59 patients (74.7%) in the PREERAS group and 73 patients (91.2%) in the ERAS group experienced at least 1 complication (risk ratio, 0.80 [95% CI, 0.67 to 0.95]; risk difference, -18.0% [CI, -27.0% to -9.0%]). LIMITATIONS: Unblinded participants and clinicians. Generalizability may be limited with longer hospital stays in the Chinese health care system. CONCLUSION: The implementation of multimodal prehabilitation in 3 tertiary hospitals in China reduced 90-day postoperative complications in older adults undergoing enhanced recovery after spinal fusion surgery. However, individual sites will need to consider applicability of findings and resource requirements of prehabilitation before implementation. PRIMARY FUNDING SOURCE: Capital's Funds for Health Improvement and Research.
2. Effect of midodrine on orthostatic intolerance after hip and knee arthroplasty: A randomized controlled trial (the MObILE study).
In this double-blind RCT in primary hip or knee arthroplasty, midodrine 10 mg reduced day-0 orthostatic intolerance (18% vs 33%; adjusted RR 0.56) and eliminated syncope events compared with placebo, with similar adverse events. Median length of stay decreased from 3 to 2 days.
Impact: Provides high-quality evidence for a simple, inexpensive pharmacologic strategy that improves early mobilization safety after major joint surgery.
Clinical Implications: Consider scheduled midodrine 10 mg in immediate postoperative protocols to reduce symptomatic orthostatic intolerance and potentially shorten length of stay, with blood pressure monitoring.
Key Findings
- Day-0 orthostatic intolerance: 18% with midodrine vs 33% with placebo (adjusted RR 0.56; p=0.038).
- Syncope occurred only in the placebo group (8%).
- Median hospital stay was 2 days with midodrine vs 3 days with placebo; adverse events were similar.
- Midodrine increased supine BP at first mobilization but did not change the rate of threshold-defined orthostatic hypotension.
Methodological Strengths
- Double-blind, randomized, placebo-controlled design with standardized orthostatic challenge.
- Continuous beat-to-beat hemodynamic monitoring and modified intention-to-treat analysis.
Limitations
- Day-1 effect was not statistically significant; single postoperative course and dosing regimen studied.
- Orthostatic hypotension by BP thresholds did not differ, raising questions about symptom-pathophysiology linkage.
Future Directions: Evaluate dose–response, patient selection (e.g., high-risk OI), integration within ERAS pathways, and effects on functional recovery and readmissions.
BACKGROUND: Orthostatic intolerance (OI), characterized by dizziness and nausea during postural change, is common after hip and knee arthroplasty and can delay mobilization and discharge. Midodrine, an oral alpha-1 agonist, may reduce OI by improving vascular tone, but evidence in this setting is limited. METHODS: A double-blind, randomized, placebo-controlled trial was performed in adults undergoing primary unilateral total hip or knee arthroplasty. Patients received oral midodrine hydrochloride 10 mg or placebo (four to five doses over 24-30 h). Mobilization included a standardized orthostatic challenge on postoperative days 0 and 1 with continuous beat-to-beat blood pressure monitoring. The primary outcome was OI during first mobilization on day 0. Secondary outcomes included OI on day 1, orthostatic hypotension, safety, hemodynamic responses, and length of stay. RESULTS: 170 patients were randomized; 159 were included in the modified intention-to-treat analysis. On day 0, OI occurred in 18% of patients receiving midodrine versus 33% receiving placebo (adjusted relative risk 0.56; p = 0.038). On day 1, OI occurred in 6% versus 15%, respectively (unadjusted relative risk 0.41; p = 0.064). Syncope occurred only in the placebo group (8%). Midodrine increased supine systolic and diastolic blood pressure at first mobilization and reduced symptom-defined OI, while the incidence of orthostatic hypotension defined by blood pressure thresholds did not differ between groups. Median length of stay was 2 days with midodrine versus 3 days with placebo. Adverse events were similar. CONCLUSION: Regular postoperative administration of midodrine 10 mg is well tolerated and reduces clinically relevant OI during early mobilization following hip and knee arthroplasty, potentially supporting safer and earlier recovery.
3. Airway Occlusions to Measure Inspiratory Effort, Respiratory Drive, and Lung Mechanics During Noninvasive Ventilation.
This multicenter physiological study demonstrates that airway occlusion pressure (Pocc) during NIV can accurately estimate inspiratory effort (ΔPes) and dynamic transpulmonary driving pressure using interface-specific conversion factors. Pocc-derived metrics identified high effort with AUC 0.97–0.98 and were associated with reintubation risk, whereas ventilator P0.1 and plateau pressure were unreliable.
Impact: Introduces a practical, noninvasive method to quantify inspiratory effort and lung stress during NIV, addressing a critical monitoring gap with direct implications for ventilatory support titration.
Clinical Implications: Bedside Pocc maneuvers can guide NIV titration to avoid excessive patient effort/lung stress and help risk-stratify for reintubation when esophageal manometry is unavailable.
Key Findings
- Interface-specific conversion factors (K) translating Pocc to ΔPes were 0.71 (oro-nasal) and 0.80 (full-face).
- Predicted ΔPes and ΔPL,dyn closely agreed with observed values; high inspiratory effort detected with AUC 0.97–0.98.
- Ventilator P0.1 poorly quantified drive, though thresholds >2.7–3 cmH2O had >90% specificity for high drive.
- More negative predicted ΔPes, higher predicted ΔPL,dyn, and lower compliance were associated with reintubation.
Methodological Strengths
- Multicenter design with esophageal manometry as reference standard.
- Cross-validation to derive interface-specific conversion factors; robust agreement analyses and ROC performance.
Limitations
- Physiological validation study without interventional outcome testing.
- Plateau pressure instability in most patients limits its utility; external validation across devices/settings is needed.
Future Directions: Prospective trials to test Pocc-guided NIV titration on clinical outcomes (reintubation, NIV failure) and to validate conversion factors across ventilators and interfaces.
RATIONALE: In intubated patients, occlusion maneuvers allow non-invasive assessment of inspiratory effort, respiratory drive and lung mechanics. OBJECTIVES: To assess the feasibility of occlusion maneuvers during noninvasive ventilation (NIV). METHODS: In this multicenter study, 60 hypoxemic patients underwent two randomized 1-hour NIV sessions with oro-nasal and full-face masks after extubation. End-expiratory and end-inspiratory occlusions measured expiratory occlusion pressure (Pocc), 100-ms airway-pressure drop (P0.1), and plateau pressure. Esophageal manometry, calibrated before extubation, provided reference values for inspiratory effort, assessed as esophageal pressure swing (ΔPes), and dynamic transpulmonary driving pressure (ΔPL,dyn = pressure support - ΔPes). Interface-specific conversion factors (K) translating Pocc into predicted ΔPes (K × Pocc) and predicted ΔPL,dyn (pressure support - predicted ΔPes) were derived through 100-interaction cross-validation (20-patient derivation set, 40-patient validation set). MAIN RESULTS: Pocc was measurable in all patients. Mean K was 0.71 with the oro-nasal mask and 0.80 with the full-face mask. Predicted ΔPes agreed with observed ΔPes (oro-nasal bias -0.41 cm H2O, 95% limits of agreement -2.3 to 1.5; full-face 0.09, -2.9 to 3.1), and predicted ΔPL,dyn agreed with observed ΔPL,dyn (oro-nasal bias 0.03, -2.9 to 2.9; full-face -0.04, -4.3 to 4.2). Predicted ΔPes identified observed ΔPes ≤ -10 cm H2O, with areas under the receiver-operating-characteristic curve of 0.98 (oro-nasal) and 0.97 (full-face). Ventilator-derived P0.1 did not precisely quantify respiratory drive, but values >2.7 cm H2O with the oro-nasal mask and >3 cm H2O with the full-face mask identified high drive with specificity >90%. Plateau pressure was unstable in 78% (oro-nasal) and 90% (full-face) of patients. More negative predicted ΔPes, higher predicted ΔPL,dyn, and lower predicted lung compliance (expiratory tidal volume/predicted ΔPL,dyn) were associated with subsequent re-intubation. CONCLUSION: During NIV, Pocc-derived parameters provide non-invasive estimates of inspiratory effort, lung stress and mechanics, whereas ventilator P0.1 and plateau pressure are less reliable.