Daily Anesthesiology Research Analysis
Analyzed 124 papers and selected 3 impactful papers.
Summary
A multicenter RCT (HISTAP) shows targeting intraoperative MAP ≥80 mmHg in high-risk hypertensive patients undergoing major abdominal surgery reduces major organ dysfunction, driven by fewer acute kidney injuries. New ATS guidelines synthesize evidence on noninvasive respiratory support, issuing strong recommendations for HFNC in hypoxemic failure and NIV in hypercapnic failure, and guidance for preoxygenation and post-extubation support. A large randomized, double-blind trial finds a single low-dose esketamine bolus during cesarean delivery lowers 6‑week postpartum depression incidence versus placebo, with fewer adverse events than continuous infusion.
Research Themes
- Intraoperative hemodynamic targets to prevent organ dysfunction
- Evidence-based use of noninvasive respiratory support across acute respiratory failure scenarios
- Peripartum mental health pharmacoprevention with esketamine
Selected Articles
1. HIgh versus STAndard blood Pressure target in hypertensive high-risk patients undergoing elective major abdominal surgery: the HISTAP multicenter randomized clinical trial.
In hypertensive adults ≥60 years undergoing major abdominal surgery, targeting intraoperative MAP ≥80 mmHg (vs ≥65 mmHg) reduced the composite of 30‑day mortality or major organ dysfunction (RR 0.78) and decreased acute kidney injury. Effects were achieved under continuous hemodynamic monitoring and protocolized fluid therapy.
Impact: This multicenter randomized trial provides practice-directing evidence that a higher intraoperative MAP target prevents organ dysfunction—particularly AKI—in a well-defined high-risk hypertensive population.
Clinical Implications: For hypertensive, high-risk patients undergoing major abdominal surgery, anesthesiologists should consider targeting MAP ≥80 mmHg with vigilant monitoring and protocolized fluids to reduce postoperative organ dysfunction, especially AKI.
Key Findings
- Primary composite outcome (mortality or major organ dysfunction) was lower with MAP ≥80 vs ≥65 mmHg (38.1% vs 48.9%; RR 0.78; 95% CI 0.65–0.93; P=0.006).
- Acute kidney injury incidence was reduced in the higher-MAP group (23.5% vs 33.7%; P=0.005).
- Mean achieved intraoperative MAPs were 88±9 mmHg (treatment) vs 77±7 mmHg (control) under continuous monitoring and protocolized fluid therapy.
Methodological Strengths
- Multicenter randomized controlled design with intention-to-treat analysis.
- Registered trial with standardized hemodynamic management and protocolized fluid therapy.
Limitations
- Open-label design may introduce performance bias; blinding of MAP targets is not feasible.
- Generalizability limited to older, hypertensive patients undergoing major abdominal surgery; effect largely driven by reductions in mild-to-moderate AKI.
Future Directions: Evaluate optimal MAP targets across broader surgical populations (including non-hypertensive patients), explore individualized autoregulation-guided targets, and assess long-term renal and cardiovascular outcomes.
PURPOSE: The optimal mean arterial pressure (MAP) target in high-risk hypertensive patients undergoing major abdominal surgery remains unclear. The HISTAP trial evaluated whether targeting an intraoperative MAP ≥ 80 compared with ≥ 65 mmHg reduces postoperative organ dysfunction and 30-day mortality, in this population. METHODS: HISTAP was a multicenter, randomized trial conducted at 18 Italian centers between March 2023 and April 2025. The study included patients aged ≥ 60 years with chronic hypertension requiring home therapy, undergoing elective major abdominal surgery and having at least one additional high-risk criterion. The intraoperative MAP was targeted to ≥ 80 mmHg (Treatment group) or ≥ 65 mmHg (Control group). The primary outcome was a composite endpoint including postoperative mortality and at least one major organ dysfunction. FINDINGS: Of 636 randomized patients, 6 were excluded since surgery was canceled after randomization, 630 completed the trial and were included in the intention-to-treat analysis (median age, 74 years [IQR, 69-79]). Mean intraoperative MAP was 77 ± 7 mmHg in the Control group and 88 ± 9 mmHg in the Treatment group. The primary composite outcome occurred in 48.9% of patients in the Control group versus 38.1% of patients in the Treatment group (relative risk, 0.78; 95% CI 0.65-0.93; P = 0.006). Acute kidney injury was significantly less frequent in the Treatment group (23.5 vs. 33.7%; P = 0.005). INTERPRETATION: Among hypertensive patients receiving continuous hemodynamic monitoring and protocolized fluid therapy at increased postoperative risk undergoing major abdominal surgery, targeting an intraoperative MAP ≥ 80 mmHg, compared with ≥ 65 mmHg, reduced major organ dysfunction, primarily due to fewer mild-to-moderate acute kidney injuries. TRIAL REGISTRATION: The HISTAP trial has been registered at ClinicalTrials.gov, NCT05637606 (Date of registration: 24 November 2022).
2. Noninvasive Respiratory Support for Adult Patients with Acute Respiratory Failure. An Official American Thoracic Society Clinical Practice Guideline.
The ATS guideline uses the GRADE framework to recommend HFNC for acute hypoxemic failure, NIV for acute hypercapnic failure, HFNC/NIV for preoxygenation, and risk-stratified HFNC (low-risk) or NIV (high-risk) after extubation. Recommendations are grounded in systematic reviews and network meta-analyses and emphasize close monitoring and escalation readiness.
Impact: This comprehensive, evidence-based guideline unifies modality and patient selection for NIRS across common ICU scenarios, offering actionable, risk-based recommendations likely to standardize care and improve outcomes.
Clinical Implications: Adopt HFNC as first-line for acute hypoxemic respiratory failure, prioritize NIV for acute hypercapnic failure, use HFNC/NIV for preoxygenation, and tailor post-extubation support (HFNC for low-risk, NIV for high-risk), with vigilant monitoring and readiness to escalate.
Key Findings
- Strong recommendation for HFNC in acute hypoxemic respiratory failure; conditional for NIV/CPAP.
- Strong recommendation for NIV in acute hypercapnic respiratory failure to reduce mortality and IMV; conditional HFNC only in mild hypercapnia (e.g., pH > 7.25) with escalation readiness.
- Strong recommendation for HFNC or NIV for preoxygenation; risk-based post-extubation strategy (HFNC for low-risk; NIV for high-risk) to reduce reintubation.
Methodological Strengths
- GRADE-based guideline informed by multiple systematic reviews and network meta-analyses.
- Multidisciplinary panel and explicit PICO questions across hypoxemia, hypercapnia, preoxygenation, and post-extubation contexts.
Limitations
- Heterogeneity of underlying evidence leads to several conditional recommendations.
- Implementation depends on institutional capacity, interface tolerance, and monitoring resources.
Future Directions: Prospective implementation studies to assess adherence and outcomes, cost-effectiveness analyses, and research defining escalation thresholds and patient-level predictors of NIRS success.
BACKGROUND: Acute hypoxemic and hypercapnic respiratory failure are among the most common reasons for ICU admission and need for invasive mechanical ventilation. Noninvasive respiratory support (NIRS) strategies-including high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and continuous positive airway pressure (CPAP)-may prevent intubation, improve outcomes, and reduce ICU utilization. However, there is uncertainty regarding optimal patient and modality selection, resulting in variable implementation. There are no clinical practice guidelines comprehensively addressing the use of the different noninvasive respiratory support strategies across the spectrum of acute respiratory failure. OBJECTIVE: To update and develop new evidence-based clinical practice recommendations informing noninvasive respiratory support use, including HFNC, NIV and CPAP, in adults with acute respiratory failure. METHODS: A multidisciplinary panel used the GRADE approach to address four PICO questions related to the use of NIRS for hypoxemic and hypercapnic respiratory failure, preoxygenation for intubation, and post-extubation respiratory support. Recommendations were informed by several systematic reviews and network meta-analyses. RESULTS: The panel made a strong recommendation for HFNC and a conditional recommendation for NIV or CPAP for adults with acute hypoxemic respiratory failure with close monitoring for the need for escalation of respiratory support, based primarily on effects on need for intubation. For acute hypercapnic respiratory failure, the panel made a strong recommendation for NIV to reduce mortality and need for invasive mechanical ventilation, and a conditional recommendation for HFNC only in patients with less severe hypercapnia and with mild acidemia (eg, pH > 7.25), provided that close monitoring and prompt escalation to NIV are available. The panel made a strong recommendation for HFNC or NIV for preoxygenation prior to endotracheal intubation to prevent peri-intubation hypoxemia. The panel also issued a risk-based recommendation, suggesting HFNC for low-risk patients and NIV for high-risk patients to reduce the need for re-intubation following extubation after critical illness. CONCLUSIONS: Noninvasive respiratory support strategies are effective in improving outcomes in a range of clinical scenarios. We provide evidence-based recommendations, which can be further informed by patient risk, institutional capacity, and interface tolerance.
3. Bolus versus Continuous Infusion of Esketamine for Prevention of Postpartum Depression After Caesarean Delivery: A Randomized, Double-Blind, Controlled Trial.
In 503 cesarean patients without prenatal depression, a single 0.25 mg/kg esketamine bolus reduced 6‑week PPD incidence versus placebo (9.15% vs 19.33%; RR 0.47), with no efficacy difference versus continuous infusion. Bolus dosing yielded fewer intraoperative adverse events than infusion, with similar analgesia across groups.
Impact: This adequately powered, double-blind RCT identifies a simple, single-dose esketamine regimen that halves 6‑week PPD risk after cesarean, with fewer adverse events than infusion—informing perioperative obstetric anesthesia strategies for mental health.
Clinical Implications: Consider a single low-dose esketamine bolus (0.25 mg/kg) intraoperatively for PPD risk reduction in cesarean patients without prenatal depression, balancing benefits against institutional protocols and monitoring for psychomimetic effects.
Key Findings
- Esketamine bolus reduced 6‑week PPD vs placebo (9.15% vs 19.33%; RR 0.47, 95% CI 0.25–0.91).
- No significant difference between bolus and continuous infusion regimens for PPD prevention (9.15% vs 11.54%; RR 0.79).
- Bolus had fewer intraoperative adverse events than infusion (45.75% vs 65.38%; RR 0.73), with comparable analgesia among groups.
Methodological Strengths
- Randomized, double-blind, controlled design with large sample size (n=503).
- Clear, patient-centered primary endpoint (EPDS >10 at 6 weeks) with prespecified safety analyses.
Limitations
- Generalizability beyond cesarean patients without prenatal depression is uncertain.
- Longer-term depression outcomes beyond 6 weeks were not assessed.
Future Directions: Replicate in diverse obstetric populations, define optimal timing and adjuncts, and evaluate longer-term maternal-infant outcomes and cost-effectiveness.
BACKGROUND: Esketamine is increasingly being applied for preventing postpartum depression (PPD). However, clinical protocols for this application are inconsistent, particularly concerning the route of administration. The aim was to determine whether esketamine bolus administration differed from continuous infusion in terms of preventing PPD. METHODS: A total of 503 subjects without prenatal depression undergoing caesarean delivery were included in this superiority trial and randomly allocated to three groups: the esketamine bolus group received a bolus injection of 0.25 mg/kg esketamine, the esketamine infusion group was administered a continuous infusion of 0.25 mg/kg esketamine, while the control group was given an equivalent volume of normal saline. Primary outcome was set as the incidence of PPD at 6 weeks postpartum. The positive screening of PPD was defined as Edinburgh Postnatal Depression Scale (EPDS) with scores of more than 10. Incidence of PPD at 1 and 4 weeks postpartum, pain scores and all adverse events were also assessed. RESULTS: Esketamine bolus administration significantly reduced the incidence of PPD compared with control group (9.15% vs 19.33%; RR 0.47, 95% CI 0.25-0.91). However, no statistically significant difference was observed between the bolus group and the infusion group (9.15% vs 11.54%; RR 0.79, 95% CI 0.40-1.57). There were no significant differences in PPD incidence at 1 and 4 weeks postpartum among the three groups. Similarly, the analgesic effects were comparable across the three groups. Regarding adverse events, less dizziness and nausea/vomiting during surgery was revealed with esketamine bolus administration. Overall, subjects receiving esketamine bolus administration also experienced fewer intraoperative adverse events than those in the infusion group (45.75% vs 65.38%, RR 0.73, 95% CI 0.56-0.95). CONCLUSION: For patients without prenatal depression undergoing caesarean delivery, esketamine bolus administration or continuous infusion demonstrated comparable efficacy for preventing PPD, bolus administration may be the preferred route due to a lower incidence of adverse events.