Daily Anesthesiology Research Analysis
Analyzed 164 papers and selected 3 impactful papers.
Summary
Three anesthesiology-focused studies stand out today: a large network meta-analysis clarifies which regional analgesia techniques most effectively reduce opioid use and pain after cardiac surgery; a randomized trial shows that placing a bronchial blocker in the lateral position virtually eliminates malposition during thoracoscopic surgery; and a single-blind randomized trial demonstrates that adding nefopam to oxycodone IV-PCA achieves non-inferior analgesia with substantial opioid sparing after laparoscopic surgery.
Research Themes
- Regional analgesia strategies for cardiac surgery and opioid stewardship
- Optimization of lung isolation techniques in thoracic anesthesia
- Opioid-sparing multimodal analgesia with nefopam in IV-PCA
Selected Articles
1. Analgesic efficacy of locoregional anesthesia techniques in cardiac surgery: a systematic review and network meta-analysis of randomized trials.
Across 133 RCTs (9,816 patients), intrathecal opioids produced the largest 24-hour reductions in opioid consumption and pain after cardiac surgery; ESPB and PIPB also reduced opioids, and several techniques shortened ICU length of stay without major block-related complications. Thoracic epidural analgesia uniquely reduced hospital length of stay by about 1.2 days.
Impact: This synthesis provides comparative effectiveness data across leading regional techniques in a domain with guideline uncertainty, supporting evidence-based opioid-sparing strategies after cardiac surgery.
Clinical Implications: Intrathecal opioids may be preferred for early postoperative analgesia when feasible; ESPB/PIPB offer neuraxial-sparing options with moderate benefits. TEA may reduce ICU and hospital stay but requires balancing risks and institutional expertise.
Key Findings
- Intrathecal opioids reduced 24-hour opioid use by −14.8 MME and produced the largest VAS pain reduction at 24 hours.
- ESPB and PIPB reduced 24-hour opioid consumption (−9.7 and −6.3 MME) and shortened ICU length of stay.
- TEA reduced ICU LOS and uniquely reduced hospital LOS by ~1.2 days.
- No major block-related complications were reported across techniques.
Methodological Strengths
- Bayesian random-effects network meta-analysis synthesizing 133 RCTs (9,816 patients)
- GRADE-based certainty assessment and multiple clinically relevant outcomes (opioids, pain, ICU/hospital LOS)
Limitations
- Substantial heterogeneity in techniques, dosing, and perioperative regimens across trials
- Effect sizes for some techniques were modest and may be below thresholds of clinical importance; limited patient-centered longer-term outcomes
Future Directions: Pragmatic, standardized multicenter RCTs comparing high-performing techniques (e.g., IT vs ESPB/PIPB) with core outcome sets and safety endpoints; head-to-head cost-effectiveness and implementation studies.
BACKGROUND: Postoperative pain following cardiac surgery remains a clinical challenge. Despite opioids remaining central to perioperative analgesia, their adverse-effect burden drives the search for effective locoregional analgesic (LRA) alternatives; yet guideline recommendations remain constrained by the lack of high-quality comparative data among LRA techniques. METHODS: This systematic review and network meta-analysis evaluated the analgesic efficacy of relevant LRA techniques in adult patients undergoing cardiac surgery. Primary outcomes were opioid consumption, pain scores, and time to first rescue analgesia within 24 hours postoperatively. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS), block-related complications, and side effects. PubMed, Embase, and CENTRAL were searched up to June 30, 2025. A Bayesian random-effects network meta-analysis was performed. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation. RESULTS: 133 randomized trials (9816 patients) were included. Compared with control, three LRA techniques reduced 24-hour opioid consumption (MME, mean difference (95% credible interval)): intrathecal opioids (IT) -14.8 (-20.7; -9.2), erector spinae plane block (ESPB) -9.7 (-14.8; -4.9), and parasternal intercostal plane block (PIPB) -6.3 (10.5; -2.3). IT produced the largest and consistent pain score reductions (-1.2 cm (-3.3; -0.7) on the visual analog scale at 24 hours). No technique prolonged time to first rescue analgesia. ESPB -8.3 hours (-13.7; -2.8), PIPB -7.2 hours (-12.2; -2.3), and TEA -11.8 hours (-20.2; -3.0) reduced ICU LOS, while only TEA reduced hospital LOS by 1.2 days (-1.7; -0.6). No major block-related complications were reported. CONCLUSIONS: IT demonstrated the largest reductions in opioid consumption and pain scores in the first 24 hours. ESPB and PIPB represent promising alternatives when neuraxial techniques are contraindicated, though effect sizes were smaller, often below thresholds of clinical relevance. Substantial interstudy heterogeneity emphasizes the need for rigorous, high-quality trials to standardize LRA strategies in cardiac surgery and to better define their impact on recovery and safety endpoints. PROSPERO REGISTRATION NUMBER: CRD42021261282.
2. Utility of bronchial blocker placement in the lateral versus supine position for thoracoscopic surgery: a randomised controlled trial in China.
Placing the bronchial blocker after positioning the patient laterally reduced malposition from 42.4% to 0% without increasing airway injury, suggesting a simple practice change can markedly improve one-lung ventilation reliability during VATS.
Impact: This pragmatic RCT addresses a common cause of intraoperative inefficiency and instability in lung isolation with a low-cost, immediately actionable intervention.
Clinical Implications: Adopting lateral-position placement after intubation can minimize pre-incision bronchoscopic adjustments and standardize reliable lung isolation in VATS, potentially streamlining workflow.
Key Findings
- BB malposition fell to 0% with lateral placement versus 42.4% with supine placement (p < 0.001).
- Absolute risk reduction 42.4% (NNT ≈ 2.36).
- Lower airway injury rates were identical (23.7% both groups), all mild-to-moderate, no severe injuries.
- Findings suggest potential to omit routine pre-incision FOB checks in selected settings.
Methodological Strengths
- Prospective randomized single-blind design with trial registration (ChiCTR2400093699)
- Objective FOB-based malposition assessment and use of penalized logistic regression (Firth) for sparse outcomes
Limitations
- Single-center, per-protocol analysis; generalizability across operator experience levels uncertain
- Short-term intraoperative outcomes only; no patient-centered postoperative endpoints
Future Directions: Multicenter trials with varied operator expertise, intention-to-treat analyses, and evaluation of postoperative outcomes and cost-effectiveness.
BACKGROUND: Bronchial blocker (BB) displacement after supine placement and subsequent patient repositioning remains a significant challenge during video-assisted thoracoscopic surgery (VATS). We aimed to test the hypothesis that placing the BB in the lateral decubitus position after standard supine tracheal intubation would reduce the incidence of malposition compared to conventional supine placement. METHODS: In this single-centre, prospective, randomised, single-blind, controlled trial conducted in China, 120 adult patients scheduled for VATS requiring one-lung ventilation were randomly assigned to either the Supine group (BB placed supine before turning lateral) or the Lateral group (BB placed after positioning the patient lateral). The primary outcome was the incidence of BB malposition, defined as the proportion of patients requiring BB repositioning (movement >1.0 cm) during the pre-incision fibreoptic bronchoscopic (FOB) check, assessed in the per-protocol population. The trial was registered with the Chinese Clinical Trial Registry, ChiCTR2400093699. FINDINGS: Between Jan 13 and May 15, 2025, among 118 patients analysed per-protocol, the incidence of BB malposition was 0% (0/59) in the lateral group compared to 42.4% (25/59) in the Supine group (Firth's penalised OR 0.011, 95% CI 0.000-0.086; p < 0.001). The absolute risk reduction was 42.4% (95% CI 28.6-54.1) with a number needed to treat of 2.36 (95% CI 1.85-3.47). Regarding the safety profile, the overall incidence of lower airway injury, as assessed by post-procedural FOB examination, was identical between groups (23.7% in each group, p = 1.000). All injuries were graded as mild or moderate (mucosal oedema or congestion); no severe injuries (haemorrhage or ulceration) were observed in either group. INTERPRETATION: Our preliminary finding show that patients undergoing VATS, placing a bronchial blocker in the definitive lateral decubitus position after standard supine intubation is a highly effective and stable strategy that virtually eliminates malposition caused by patient repositioning. This strategy not only improves the reliability of lung isolation but also offers the potential, in the future, to omit the routine pre-incision bronchoscopic check, further enhancing procedural efficiency. Future multicentre trials involving operators with varying levels of experience are needed to validate the generalisability of these findings. FUNDING: The Ningbo Medical and Health Brand Discipline.
3. Adding nefopam to oxycodone-based patient-controlled analgesia provides noninferior analgesia with opioid sparing after laparoscopic surgery.
In a single-blind randomized non-inferiority trial, adding nefopam (120–200 mg) to oxycodone IV-PCA achieved non-inferior 24-hour pain control while reducing oxycodone use by 26–47% over 96 hours, without increased sedation or respiratory depression.
Impact: Provides randomized evidence for an opioid-sparing multimodal IV-PCA regimen after laparoscopic surgery with maintained analgesia and no added safety signal.
Clinical Implications: Consider nefopam as an adjunct in oxycodone-based IV-PCA to reduce opioid exposure post-laparoscopy, particularly in ERAS pathways; confirmatory double-blind studies would support broader adoption.
Key Findings
- Non-inferior 24-hour resting VAS with nefopam-oxycodone versus oxycodone alone (non-inferiority margin 1.0).
- Cumulative oxycodone use reduced by 26.2% (nefopam 120 mg) and 46.7% (nefopam 200 mg) at 96 hours (both p < 0.001).
- No increase in adverse events, sedation, or respiratory depression across groups.
- Trial registered (KCT0003896); ITT analysis performed.
Methodological Strengths
- Randomized single-blind non-inferiority design with two active-dose arms and ITT analysis
- Clinically meaningful endpoints (pain, opioid consumption) and safety monitoring; trial registration
Limitations
- Single-center and single-blind design; external validity may be limited
- Non-inferiority focused on 24-hour resting VAS; functional outcomes and longer-term recovery not assessed
Future Directions: Double-blind multicenter RCTs with fixed-opioid dosing, functional recovery endpoints, and comparative cost-effectiveness analyses.
To evaluate the analgesic efficacy and opioid-sparing effect of two different doses of nefopam combined with oxycodone in intravenous patient-controlled analgesia (IV PCA) compared with oxycodone alone after laparoscopic abdominal surgery. In this single-center, randomized, single-blind, non-inferiority trial, 246 patients undergoing elective laparoscopic gastrointestinal or colorectal surgery were randomly assigned (1:1:1) to Group A (oxycodone 160 mg + nefopam 120 mg), Group B (oxycodone 130 mg + nefopam 200 mg), or Group C (oxycodone 200 mg, control), each in a 200 mL PCA bag. The primary endpoint was visual analogue scale (VAS) pain score at rest at 24 h postoperatively, with a non-inferiority margin of 1.0. Secondary endpoints included cumulative oxycodone consumption, rescue medication use, quality of recovery, and adverse events. A total of 230 patients were included in the intention-to-treat analysis. Both nefopam-oxycodone combinations were non-inferior to oxycodone monotherapy for the primary endpoint (mean difference, Group A vs. C: -0.33, 95% CI - 0.81 to 0.15; Group B vs. C: 0.00, 95% CI - 0.50 to 0.51). Cumulative oxycodone consumption at 96 h was reduced by 26.2% in Group A and 46.7% in Group B compared with the control group (both P < 0.001). The incidences of any adverse event, sedation, and respiratory depression did not differ among the three groups. In this single-blind trial, adding nefopam to oxycodone-based IV PCA provided non-inferior analgesia while substantially reducing opioid consumption after laparoscopic abdominal surgery. These results require confirmation in a double-blind trial with a fixed-opioid-dose design.Trial Registration: This study was registered at the Clinical Research Information Service of the Korean National Institute of Health (CRIS, http//cris.nih.go.kr), with registration number KCT0003896.