Daily Anesthesiology Research Analysis
Analyzed 105 papers and selected 3 impactful papers.
Summary
Analyzed 105 papers and selected 3 impactful articles.
Selected Articles
1. Early high-dose vitamin C for out-of-hospital cardiac arrest: the VITaCCA randomized clinical trial.
In 273 randomized patients, high-dose vitamin C (10 g/day) worsened organ dysfunction compared with placebo at 96 h, yielding 2.5 points less improvement in R-SOFA and higher troponin T, worse renal function, and poorer neurological outcomes. The 3 g dose did not improve organ dysfunction over placebo.
Impact: This well-designed multicenter RCT provides definitive negative and safety signals against high-dose vitamin C after cardiac arrest, directly informing practice and future guidelines.
Clinical Implications: Avoid supraphysiologic (10 g/day) vitamin C after out-of-hospital cardiac arrest outside of trials; do not expect benefit from 3 g/day; prioritize proven post–cardiac arrest care bundles.
Key Findings
- Primary endpoint: mean 96 h R-SOFA change was −3.2 (placebo), −2.3 (3 g), and −0.8 (10 g); overall p=0.04.
- 10 g vitamin C resulted in 2.5 points less R-SOFA improvement vs placebo (95% CI 0.5–4.5; p=0.01).
- 10 g vitamin C increased troponin T release, worsened renal function, and worsened neurological outcomes.
- No clinical benefit was observed with 3 g/day vs placebo on organ dysfunction.
Methodological Strengths
- Double-blind, multicenter randomized design with dose–response comparison
- Pre-registered trial with clinically relevant, objective endpoints
Limitations
- Phase 2 design may be underpowered for some patient-centered secondary outcomes
- Generalizability limited to shockable OHCA and trial settings
Future Directions: Further trials should clarify mechanisms of harm at supraphysiological dosing, evaluate timing/biomarker-guided dosing, and focus on patient-centered outcomes and subgroups.
BACKGROUND: Besides temperature management, there is currently no effective therapy to decrease the burden of post-cardiac arrest syndrome. The pleiotropic effects of vitamin C may improve clinical outcome. PURPOSE: This trial investigated whether early administration of 3 g or 10 g intravenous vitamin C attenuated organ dysfunction post-cardiac arrest. METHODS: In this double-blind, multi-center, phase 2 trial, comatose adults resuscitated from shockable out-of-hospital cardiac arrest randomly received intravenously placebo, supplementary (3 g) or supraphysiological dose (10 g) vitamin C daily for 96 h. The primary endpoint was the 96 h change in the resuscitation-sequential organ failure assessment (R-SOFA) score. Secondary endpoints included neurological outcome, myocardial injury, vasopressor- and ventilator-free days, renal function, ICU-acquired weakness, delirium, length of ICU and hospital stay, and 28- and 180-day mortality.
2. The prophylactic use of tranexamic acid in orthotopic liver transplantation: A randomized placebo-controlled study.
In a double-blind RCT of 138 OLT recipients, prophylactic TXA did not significantly reduce major bleeding overall but reduced intraoperative RBC transfusion and length of stay, with safety comparable to placebo. Subgroup benefits were observed in lower-risk profiles (MELD ≤9, Child-Pugh A).
Impact: This trial refines antifibrinolytic strategy in OLT, supporting selective rather than routine TXA use and providing safety reassurance.
Clinical Implications: Do not adopt routine prophylactic TXA for all OLT; consider selective use in lower-risk recipients to reduce transfusions and length of stay without increasing thromboembolism.
Key Findings
- Primary outcome (major bleeding ≤24 h): TXA 48.5% vs placebo 62.9%; RR 0.77 (95% CI 0.56–1.04); p=0.09.
- Significant subgroup reductions in major bleeding for MELD ≤9 (p=0.01) and Child-Pugh A (p=0.01).
- Lower intraoperative RBC transfusion in TXA group (median 0 [IQR 0–3] vs 2 [0–5] units; p=0.01).
- Shorter hospital length of stay with TXA (20 [14–31] vs 25 [18–37] days; p=0.04).
- No increase in thromboembolic events or mortality with TXA.
Methodological Strengths
- Double-blind randomized controlled design with clinically meaningful endpoints
- Standardized dosing protocol and balanced safety assessment
Limitations
- Sample size may be underpowered for the primary endpoint and for thromboembolic safety signals
- Subgroup findings require cautious interpretation and external validation
Future Directions: Larger, multicenter trials should validate targeted TXA strategies (risk-stratified dosing/timing) and assess transfusion-independent patient-centered outcomes.
Perioperative bleeding during orthotopic liver transplantation (OLT) is primarily driven by hyperfibrinolysis and impaired coagulation, resulting in elevated morbidity, mortality, and transfusion requirements. Although tranexamic acid (TXA) has been shown to reduce bleeding in various surgical settings, its prophylactic efficacy and safety in OLT remain unclear. We conducted a double-blinded, randomized controlled trial involving 138 adult patients undergoing OLT, who were assigned to receive either TXA (10 mg/kg bolus followed by a 1 mg/kg/h infusion) or placebo (0.9% saline). The primary outcome was the incidence of major bleeding within 24 hours of the surgical incision. Secondary outcomes included red blood cell transfusion volume, hospital length of stay, and postoperative complications. The overall incidence of major bleeding did not differ significantly between groups (TXA: 48.5% vs. placebo: 62.9%; relative risk [RR] 0.77 [95% CI 0.56-1.04]; p=0.09). However, significant reductions were observed in subgroups with MELD 3.0 scores ≤9 (p=0.01) and Child-Pugh A classification (p=0.01). The TXA group had lower median intraoperative red blood cell transfusions (0 unit [IQR 0-3] vs. 2 units [IQR 0-5]; p=0.01) and shorter hospital length of stay (20 days [IQR 14-31] vs. 25 days [IQR 18-37]; p=0.04). No significant differences were found in thromboembolic complications or mortality. In conclusion, prophylactic TXA does not significantly reduce the incidence of major perioperative bleeding in OLT but may benefit lower-risk subgroups by reducing transfusion requirements and shortening hospital stays, without increasing thromboembolic or mortality risks. These findings suggest a selective role for TXA in OLT, warranting larger confirmatory trials to guide targeted use.
3. Hypotension prediction index in surgical patients: A systematic review and meta-analysis of randomized controlled trials.
Across 18 RCTs (n=2279 noncardiac) and 1 cardiac RCT (n=130), HPI-guided management significantly reduced multiple metrics of intraoperative hypotension and lowered intraoperative fluids and phenylephrine use. No significant difference was found for postoperative AKI.
Impact: This RCT-only meta-analysis clarifies that HPI meaningfully reduces intraoperative hypotension but does not yet translate into improved renal outcomes, guiding realistic expectations and implementation.
Clinical Implications: HPI can be adopted to reduce intraoperative hypotension and vasopressor/fluid exposure, but teams should pair alerts with standardized response algorithms and continue outcome monitoring, as organ-protection benefits remain unproven.
Key Findings
- HPI guidance reduced time-weighted average hypotension (WMD −0.19; 95% CI −0.25 to −0.12).
- Area under threshold decreased (WMD −55.17; 95% CI −73.62 to −36.71).
- Incidence of IOH reduced (WMD −2.42; 95% CI −3.36 to −1.49) and cumulative duration reduced (WMD −10.61; 95% CI −14.11 to −7.11).
- Intraoperative fluids and phenylephrine use were reduced; postoperative AKI showed no significant difference (OR 0.83; 95% CI 0.64–1.07; p=0.16).
Methodological Strengths
- PRISMA-2020–adherent meta-analysis restricted to randomized controlled trials
- Multiple complementary hypotension metrics with consistent effect direction
Limitations
- High heterogeneity and varying HPI thresholds/response protocols across trials
- No demonstrated improvement in hard clinical outcomes such as AKI
Future Directions: Standardize HPI alert thresholds and treatment bundles; power future trials for patient-centered outcomes (AKI, myocardial injury, stroke) and cost-effectiveness.
BACKGROUND: The Hypotension Prediction Index (HPI) is a machine-learning-derived early-warning algorithm that uses real-time arterial pressure waveform features to prospectively identify episodes of intraoperative hypotension (IOH) - defined as mean arterial pressure < 65 mm Hg sustained for ≥ 1 minute. IOH is a common hemodynamic complication in surgical patients and is associated with impaired end-organ perfusion and an increased risk of postoperative morbidity. To rigorously evaluate the predictive performance of HPI and its impact on IOH, we conducted a systematic review and meta-analysis of randomized controlled trials, adhering strictly to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement. METHODS: A systematic literature search was conducted across multiple electronic databases from their inception to April 10, 2026. The search strategy employed a combination of keyword terms, including "hypotension," "prediction," "index," "surgery," and "randomized controlled trial." Primary outcomes were the time-weighted average, area under the threshold, incidence, and duration of IOH. Secondary outcomes included intraoperative fluid administration, estimated blood loss, urine output, use of vasopressors and inotropes, and postoperative acute kidney injury (AKI). Pooled effect estimates were calculated using odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes, with corresponding 95% confidence intervals.