Daily Anesthesiology Research Analysis
Analyzed 129 papers and selected 3 impactful papers.
Summary
Analyzed 129 papers and selected 3 impactful articles.
Selected Articles
1. Computed Tomography-Based Body Composition Assessment for Preoperative Cardiovascular Risk Prediction: A Prospective Cohort Study.
In two prospective cohorts (n=1,594), CT-based metrics at L3 (skeletal muscle area, muscle radiodensity, subcutaneous fat radiodensity) significantly improved 30-day postoperative cardiovascular event prediction beyond RCRI, Gupta MICA, and a refitted clinical model, and were externally validated. Larger muscle and fat areas were protective, whereas high fat radiodensity and low muscle radiodensity indicated higher risk.
Impact: Demonstrates a practical way to leverage routinely available preoperative CT to materially enhance perioperative cardiovascular risk prediction and validates it across cohorts.
Clinical Implications: When preoperative abdominal CT is available, incorporating L3 muscle area/radiodensity and subcutaneous fat radiodensity can refine 30-day cardiovascular risk stratification beyond guideline tools, informing monitoring, optimization, and shared decision-making.
Key Findings
- In 1,594 patients, 211 (13.2%) had 30-day cardiovascular events.
- An optimal subset (skeletal muscle area, muscle radiodensity, subcutaneous fat radiodensity) improved discrimination over RCRI (ΔAUC 0.136; 95% CI 0.083–0.188).
- Findings were externally validated in an independent cohort (PREVENGE-CB).
- Larger skeletal muscle/adipose areas associated with lower risk; high adipose radiodensity and low muscle radiodensity associated with higher risk.
Methodological Strengths
- Prospective multicenter design with external validation.
- Direct comparisons to established predictors (RCRI, Gupta MICA) using multiple performance metrics (ΔAUC, reclassification, net benefit).
Limitations
- Generalizability may be limited to centers with routine preoperative abdominal CT.
- Observational design cannot establish causality; potential selection biases in who undergoes CT.
Future Directions: Prospective implementation studies testing clinical workflows that integrate automated CT body composition extraction, with impact on management decisions and outcomes; evaluation across diverse populations without routine CT, and exploration of non-CT surrogates.
BACKGROUND: Current approaches for preoperative cardiovascular risk prediction remain suboptimal. CT-derived body composition metrics may provide objective markers of cardiometabolic health, yet their predictive value for postoperative cardiovascular events remains unclear. METHODS: We included patients with cardiovascular disease or risk factors undergoing major noncardiac surgery in the prospective, multicenter PREVENGE-CB (PREdiction of Vascular Events after Noncardiac surGEry with Cardiac Biomarkers) cohort and its Nanfang extension. Preoperative abdominal CT scans were analyzed to quantify the area and radiodensity of skeletal muscle and adipose tissues at the third lumbar vertebral level. The primary outcome was composite cardiovascular events within 30 days after surgery. We used logistic regression models to evaluate the added predictive value of body composition metrics beyond guideline-recommended predictors. In the Nanfang cohort, the optimal subset of body composition metrics was selected by minimizing the Akaike Information Criterion for the primary outcome. Nested models were compared using measures of model fit, discrimination, risk reclassification, and net benefit. The findings were validated in the PREVENGE-CB cohort. RESULTS: Among 1594 patients, 211 (13.2%) had the primary outcome. Larger skeletal muscle and adipose areas were generally associated with lower risk, whereas higher adipose radiodensity and lower muscle radiodensity indicated higher risk. In the Nanfang cohort, an optimal subset of three body composition metrics-skeletal muscle area, muscle radiodensity and subcutaneous fat radiodensity-improved discrimination of the primary outcome over the Revised Cardiac Risk Index (increase in area under the curve [ΔAUC] = 0.136; 95% CI, 0.083 to 0.188), the Gupta Myocardial Infarction and Cardiac Arrest risk calculator (ΔAUC = 0.032; -0.002 to 0.065), and a refitted clinical model (ΔAUC = 0.035; 0.008 to 0.062). These findings were validated in the PREVENGE-CB cohort. CONCLUSIONS: CT-derived body composition metrics improved prediction of postoperative cardiovascular events beyond conventional clinical predictors.
2. Ultrasound-guided erector spinae plane block versus serratus anterior plane block for analgesia and respiratory function in patients with multiple rib fractures: a large-sample, single-center, randomized, double-blind, controlled trial.
In a double-blind randomized trial of 158 patients with unilateral multiple rib fractures, ESPB achieved significantly lower 24-hour pain AUC and reduced opioid requirements compared with SAPB, without safety trade-offs. Findings support ESPB as a preferred first-line regional technique in this setting.
Impact: Provides high-quality comparative RCT evidence guiding block selection for rib fracture analgesia, a frequent and clinically consequential pain indication in acute care and anesthesia.
Clinical Implications: For unilateral multiple rib fractures, prioritize ESPB over SAPB to improve early analgesia and reduce perioperative opioid exposure, while maintaining safety. Incorporate ESPB into rib fracture care pathways, especially in patients with fewer fractured ribs.
Key Findings
- Randomized, double-blind comparison (n=158) of ESPB vs SAPB in unilateral multiple rib fractures.
- ESPB produced significantly lower 24-hour pain AUC than SAPB (mean difference −17.78; 95% CI −21.00 to −14.56).
- ESPB reduced opioid requirements without compromising safety.
- Trial registration: ChiCTR2300067544.
Methodological Strengths
- Randomized, double-blind, controlled design with adequate sample size for a block comparison.
- Clinically relevant outcomes (pain AUC over 24 h, opioid consumption) and safety assessment.
Limitations
- Single-center design may limit generalizability.
- Details of respiratory function endpoints and longer-term outcomes are limited in the abstract.
- Technique standardization and operator expertise may influence effect size.
Future Directions: Multicenter trials including diverse fracture burdens and standardized respiratory outcomes; cost-effectiveness and implementation studies integrating ESPB into rib fracture care pathways; comparative effectiveness versus neuraxial or paravertebral techniques.
OBJECTIVE: This large-sample, randomized, double-blind controlled trial directly compared the analgesic efficacy and impact on respiratory function of ultrasound-guided erector spinae plane block (ESPB) versus serratus anterior plane block (SAPB) in patients with unilateral multiple rib fractures. METHODS: A total of 158 eligible patients were randomized to receive either ESPB ( RESULTS: The ESPB group demonstrated a significantly lower 24-h pain AUC compared to the SAPB group (mean difference -17.78, 95% CI: -21.00 to -14.56, CONCLUSION: For patients with unilateral multiple rib fractures, ESPB provides significantly better early comprehensive analgesia and reduces opioid requirements compared to SAPB, without compromising safety. ESPB may be considered as a preferred first-line regional analgesic technique, especially for patients with a lower fracture burden. CLINICAL TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR), Registration No. ChiCTR2300067544.
3. Prognostic value of the Duke Activity Status Index for preoperative cardiac risk stratification: an international pooled cohort study.
In pooled prospective cohorts (n=3,485), DASI added prognostic information for 30-day major cardiac events or death beyond age, RCRI, and natriuretic peptides, improving multiple performance metrics. However, overall discrimination remained modest (c-index ~0.70–0.71), supporting DASI as a continuous, context-dependent adjunct rather than a stand-alone threshold tool.
Impact: Refines understanding of how to use DASI alongside biomarkers and clinical scores in contemporary preoperative assessment, aligning functional capacity measurement with evidence-based, context-aware interpretation.
Clinical Implications: Use DASI as a continuous variable integrated with RCRI and natriuretic peptides to refine risk discussions; avoid rigid cutoffs. Expect modest discrimination and prioritize multimodal assessment for decision-making.
Key Findings
- Among 3,485 patients, 3.6% had 30-day major cardiac complications or death.
- DASI provided incremental prognostic value beyond age, RCRI, and natriuretic peptide concentration (LRT p=0.009).
- Overall discrimination remained modest (c-index 0.70–0.71) with limited net clinical benefit.
- Predicted risks for a given DASI score varied substantially by age, RCRI, and natriuretic peptides, supporting continuous interpretation.
Methodological Strengths
- Pooled analysis of two prospective cohorts with prespecified hierarchical modeling and comprehensive performance metrics.
- Concurrent assessment of DASI with guideline-recommended biomarkers enabling incremental value testing.
Limitations
- Modest discrimination and limited net clinical benefit reduce stand-alone utility.
- Heterogeneity across cohorts and potential residual confounding inherent to observational data.
Future Directions: Decision-impact and cost-effectiveness studies integrating DASI with biomarkers and imaging-derived markers; evaluate adaptive thresholds tailored by age, RCRI, and natriuretic peptide levels.
BACKGROUND: Guidelines recommend structured self-reported functional capacity assessment for preoperative cardiac risk stratification, including the Duke Activity Status Index (DASI). However, evidence supporting its incremental prognostic value beyond established risk factors remains limited. We evaluated the prognostic performance of the DASI using pooled data from two prospective cohorts. METHODS: We conducted a pooled cohort analysis of adults undergoing elective major non-cardiac surgery enrolled in the Measurement of Exercise Tolerance before Surgery (METS) and Functional Improvement Trajectories After Surgery (FIT After Surgery) studies, including data collected between March 2013 and April 2023. Before surgery, participants completed the Duke Activity Status Index (DASI), a structured 12-item questionnaire based on daily physical activities, and underwent routine preoperative biomarker measurement. The primary outcome was 30-day major cardiac complications (myocardial infarction or non-fatal cardiac arrest) or death. The secondary outcome was all-cause major complications. Hierarchical logistic regression assessed the incremental prognostic value of the DASI beyond age, Revised Cardiac Risk Index (RCRI), and natriuretic peptide concentration. Prognostic performance was evaluated using the likelihood ratio test (LRT), fraction of new predictive information, net reclassification improvement, c-index, calibration plots, and decision curve analysis. FINDINGS: Among 3485 patients, 3.6% (n = 126) experienced the primary outcome and 19% (n = 647) experienced the secondary outcome. The DASI provided prognostic information beyond age, RCRI, and natriuretic peptide concentration for the primary outcome (LRT p = 0.009), and beyond age, sex, and surgery type for the secondary outcome (LRT p < 0.001). Inclusion of the DASI improved prognostic performance across multiple metrics, but overall discrimination of the final models remained modest (c-index 0.70-0.71), with limited net clinical benefit. Predicted risk associated with a given DASI score varied substantially by age, RCRI, and natriuretic peptide concentration, supporting interpretation of the DASI as a continuous prognostic marker rather than a dichotomous screening test. INTERPRETATION: The DASI provides incremental prognostic information for preoperative cardiac risk assessment beyond guideline-recommended predictors. Its prognostic implications are modest, context-dependent, and best interpreted as a continuous prognostic marker alongside established risk factors, rather than as a stand-alone threshold-based tool. FUNDING: Canadian Institutes of Health Research; PSI Foundation; and the Elizabeth A. and Richard J. Currie, O.C. Chair in Translational Anesthesia Research at St. Michael's Hospital and the University of Toronto; The Ottawa Hospital Academic Medical Organization Innovation Fund; Heart and Stroke Foundation of Canada; Ontario Ministry of Health and Long-Term Care; Ontario Ministry of Research, Innovation and Science; UK National Institute of Academic Anaesthesia; UK Clinical Research Collaboration; Australian and New Zealand College of Anaesthetists; Monash University.