Daily Anesthesiology Research Analysis
Analyzed 77 papers and selected 3 impactful papers.
Summary
Three impactful anesthesiology/critical care studies stood out today: a multicenter RCT found that adding CBT or self-management to patient-centered opioid tapering did not improve 12-month taper success; a randomized noninferiority trial showed single-shot intrathecal morphine provides noninferior overall and superior early analgesia versus continuous wound infiltration after pancreatoduodenectomy albeit with more early side effects; and a physiologic study linked capillary refill time changes to the vascular waterfall in post-cardiac surgery patients, offering a mechanistic basis for CRT-guided resuscitation.
Research Themes
- Opioid stewardship and tapering strategies
- Perioperative analgesia optimization
- Microcirculation-guided resuscitation physiology
Selected Articles
1. Patient-Centered Prescription Opioid Tapering Methods : A Randomized Clinical Trial.
In a multicenter RCT (n=562), adding pain-focused CBT or a chronic pain self-management program to patient-centered opioid tapering did not improve 12-month taper success compared with tapering alone. Adverse events, including withdrawal symptoms, were most frequent with taper-only, suggesting CBT may mitigate side effects even without improving success rates.
Impact: This rigorously conducted, registered RCT addresses a central question in opioid stewardship and challenges assumptions that routine behavioral add-ons improve taper outcomes. It provides practice-informing negative evidence while highlighting potential safety benefits of CBT.
Clinical Implications: Patient-centered tapering with monitoring can be implemented without routine CBT/CPSMP to achieve taper success; CBT may be selectively used to reduce withdrawal-related adverse effects. Programs should focus on engagement and monitoring rather than assuming added behavioral interventions improve taper outcomes.
Key Findings
- 12-month taper success: 50.9% (taper only) vs 48.6% (taper+CBT) vs 44.5% (taper+CPSMP); no significant differences.
- Adverse event risk highest with taper-only (66%) vs taper+CBT (54%) and taper+CPSMP (64%).
- COVID-19–related imbalances and low behavioral session attendance may have limited behavioral arm effects.
Methodological Strengths
- Multicenter, randomized controlled design with prespecified primary outcome and trial registration.
- Patient-centered, pragmatic outcome definition capturing both dose reduction and pain.
Limitations
- Pandemic-related enrollment challenges created group imbalances; behavioral attendance and follow-up losses were suboptimal.
- Open-label behavioral interventions limit blinding; potential performance bias.
Future Directions: Identify subgroups benefiting from CBT (e.g., high withdrawal risk), optimize digital engagement strategies, and assess long-term functional outcomes and opioid-related harms beyond 12 months.
BACKGROUND: Evidence is needed on tapering long-term prescription opioids in outpatient settings. OBJECTIVE: To determine and compare the effectiveness of 3 opioid tapering and pain control strategies (July 2018 to November 2023). DESIGN: Randomized controlled trial. (ClinicalTrials.gov: NCT03445988). SETTING: 11 U.S. sites. PARTICIPANTS: Adults with pain for at least 6 months receiving a morphine equivalent daily dose (MEDD) of 10 or higher for at least 3 months without moderate or severe opioid use disorder. INTERVENTION: Patient-centered opioid tapering with close monitoring and electronic supports was administered as taper only, taper plus cognitive behavioral therapy for chronic pain (pain-CBT), or taper plus a chronic pain self-management program (CPSMP). MEASUREMENTS: Taper success (primary outcome) was either an MEDD decrease of at least 50% with no increased pain or no MEDD increase with decreased pain intensity. RESULTS: A total of 562 participants were randomly assigned (191 taper only, 203 taper plus pain-CBT, 168 taper plus CPSMP). The taper success rate was 50.9% (95% CI, 42.9% to 58.9%) for taper only, 48.6% (CI, 41.0% to 56.2%) for taper plus pain-CBT, and 44.5% (CI, 36.0% to 53.3%) for taper plus CPSMP. Tapering with pain-CBT or CPSMP provided no benefit in taper success over taper only (taper plus pain-CBT vs. taper only, -2.4 percentage points [CI, -11.9 to 7.2 percentage points]; taper plus CPSMP vs. taper only, -5.2 percentage points [CI, -15.3 to 4.8 percentage points]). Study-related adverse event risk (including opioid withdrawal symptoms) was highest in the taper only group (126 of 191 [66%]) compared with taper plus pain-CBT (109 of 203 [54%]) and taper plus CPSMP (108 of 168 [64%]). LIMITATION: Challenges related to COVID-19 reduced the sample size and made treatment groups imbalanced; low behavioral treatment attendance and losses to follow-up could have limited effectiveness. CONCLUSION: Adding CBT or self-management to patient-centered opioid tapering did not improve taper success at 12 months, although CBT may reduce adverse effects (including opioid withdrawal symptoms). PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.
2. A randomized, noninferiority clinical trial of Single-Shot Intrathecal Morphine versus Continuous Wound Infiltration for postoperative pain control after open pancreatoduodenectomy.
In adults undergoing open pancreatoduodenectomy, single-shot intrathecal morphine (0.2 mg) was noninferior to continuous wound infiltration for mean coughing pain over 24–72 hours and provided superior early analgesia with reduced IV-PCA fentanyl use. Early respiratory depression and pruritus were more frequent with intrathecal morphine, warranting close monitoring.
Impact: Direct head-to-head randomized evidence between two epidural alternatives in major abdominal surgery fills an important evidence gap and can immediately inform analgesic strategy selection.
Clinical Implications: Single-shot intrathecal morphine is a viable, simplified alternative to continuous wound infiltration for open pancreatoduodenectomy, offering strong early analgesia; clinicians should balance benefits against increased early respiratory depression and pruritus with appropriate monitoring and rescue protocols.
Key Findings
- Primary noninferiority met for mean coughing pain over 24–72 h: ITM 5.7 vs CWI 6.1 (mean difference -0.5; 95% CI -1.1 to 0.2).
- ITM reduced pain at 2 h (rest and cough) with sustained cough-pain reduction at 24 h and lower IV-PCA fentanyl use.
- Early adverse effects were higher with ITM: increased respiratory depression and pruritus within 24 h.
Methodological Strengths
- Randomized noninferiority design with standardized multimodal analgesia and IV-PCA across arms.
- Clinically meaningful primary endpoint (cough pain averaged over 24–72 h) with prespecified margin.
Limitations
- Open-label, single-center design; per-protocol analysis with modest sample size (n=92) may limit generalizability and rare event detection.
- Short-term analgesia outcomes; limited data on longer-term recovery and complications.
Future Directions: Pragmatic multicenter trials, dose-finding for intrathecal morphine, risk stratification for respiratory events, and comparisons versus thoracic epidural analgesia are warranted.
BACKGROUND: Intrathecal morphine (ITM) and continuous wound infiltration (CWI) are two alternatives to thoracic epidural analgesia in major abdominal surgery, but direct comparative studies are lacking. We evaluated whether ITM is noninferior to CWI after open pancreatoduodenectomy. METHODS: An open-label, randomised, noninferiority clinical trial conducted at a tertiary hospital. Adult patients undergoing elective open pancreatoduodenectomy were randomised 1:1 to receive either a single-shot ITM (0.2 mg) or bilateral preperitoneal CWI. Both groups received standardised multimodal and intravenous patient-controlled analgesia (IV-PCA). The primary outcome was the mean coughing pain score, averaged across 24, 48, and 72 h postoperatively, analysed for noninferiority using the 95% confidence interval (noninferiority margin: 1.0). Secondary outcomes included the mean resting pain score, pain score at each time point (2, 24, 48, and 72 h), IV-PCA fentanyl consumption, EuroQol 5-Dimension 5-Level utility score, and postoperative complications. RESULTS: In the per-protocol population (n = 92), ITM was noninferior to CWI for the primary outcome (ITM: 5.7 ± 1.7 vs. CWI: 6.1 ± 1.5; mean difference -0.5, 95% confidence interval -1.1 to 0.2). ITM was also noninferior to CWI regarding the mean resting pain score. ITM provided significantly lower pain scores at 2 h postoperatively, both at rest and on coughing, with a sustained reduction on coughing at 24 h and reduced fentanyl consumption. Otherwise comparable, ITM increased respiratory depression and pruritus within 24 h. CONCLUSION: ITM provides noninferior overall and superior early analgesia to CWI after open pancreatoduodenectomy, although careful monitoring for early side effects is warranted. TRIAL REGISTRATION: ClinicalTrials.gov Identifier (No. NCT06761989, https://clinicaltrials.gov/study/NCT06761989) registered on 30 December 2024.
3. Capillary refill time changes are associated with Vascular Waterfall response in post-cardiac surgery patients.
Among post-cardiac surgery patients with acute circulatory failure, prolonged baseline CRT was associated with low vascular waterfall, and treatment-induced ΔCRT tracked ΔVW, driven by changes in critical closing pressure rather than mean systemic filling pressure. ΔCRT independently predicted VW response irrespective of hemodynamic phenotype, providing a physiologic basis for CRT-guided resuscitation.
Impact: By linking a bedside perfusion sign (CRT) to microcirculatory driving pressure physiology (vascular waterfall), this study advances mechanistic understanding and supports CRT-targeted strategies in postoperative critical care.
Clinical Implications: CRT can serve as a pragmatic surrogate for changes in microcirculatory perfusion pressure after cardiac surgery, potentially guiding vasopressor, fluid, and inotrope titration; emphasis should be on arterial-side determinants (critical closing pressure).
Key Findings
- Baseline prolonged CRT (>3 s) associated with lower vascular waterfall (2.8 vs 18.3 mmHg; p=0.014).
- ΔCRT correlated with ΔVW (ρ=-0.40, p<0.001) and with ΔPcc (ρ=-0.42) but not with ΔPmsf (ρ=-0.03).
- ΔCRT independently predicted VW response in multivariable analysis (OR 0.31 per second; p=0.021), unaffected by phenotype.
Methodological Strengths
- Prospective physiological measurements with standardized CRT and inspiratory hold-derived VW components.
- Predefined hemodynamic phenotypes and multivariable modeling across treatment modalities.
Limitations
- Secondary analysis with modest single-center sample size (n=74); limited external generalizability.
- Observational design precludes causal inference and lacks patient-centered outcome linkage.
Future Directions: Multicenter interventional trials testing CRT-guided titration with vascular waterfall endpoints and evaluation of impacts on organ dysfunction and mortality.
BACKGROUND: Capillary refill time (CRT) has emerged as a validated resuscitation target in acute circulatory failure following the ANDROMEDA-SHOCK trials and the 2025 ESICM guidelines, yet the physiological mechanisms underlying its clinical utility remain incompletely understood. The vascular waterfall (VW), defined as the difference between critical closing pressure (Pcc) and mean systemic filling pressure (Pmsf), represents the pressure gradient driving microcirculatory flow. We hypothesized that CRT changes reflect VW changes during hemodynamic treatment in post-cardiac surgery patients. METHODS: This was a secondary analysis of a prospective observational study conducted in post-cardiac surgery patients with acute circulatory failure (n = 74). Patients were classified into vasoplegic (n = 30), preload-dependent (n = 33), or cardiogenic (n = 11) phenotypes and treated with norepinephrine, fluid expansion, or dobutamine, respectively. Hemodynamic parameters that comprise mean arterial pressure (MAP), indexed systemic arterial resistances (SARi), indexed venous resistances (VRi) were measured before and after treatment. VW was measured using the inspiratory hold technique before and after treatment. CRT was assessed using standardized methodology. Associations between CRT and VW changes were evaluated using Spearman correlations and multivariable logistic regression. RESULTS: Patients with prolonged baseline CRT (>3 seconds, n = 55) had significantly lower VW compared to those with normal CRT (2.8 vs 18.3 mmHg, p = 0.014). Changes in CRT correlated significantly with changes in VW across the entire cohort (ρ = -0.40, p < 0.001). Subgroup analysis showed a significant correlation in preload-dependent patients (ρ = -0.37, p = 0.032), with similar trends in vasoplegic (ρ = -0.34, p = 0.065) and cardiogenic groups (ρ = -0.20, p = 0.555). Notably, ΔCRT correlated with ΔPcc (ρ = -0.42, p < 0.001) but not with ΔPmsf (ρ = -0.03, p = 0.81), indicating that CRT changes were more closely associated with the arterial component of vascular waterfall. In multivariable logistic regression, ΔCRT independently predicted VW response (OR 0.31 per second, 95% CI 0.12-0.84, p = 0.021), alongside ΔMAP, ΔSARi, and ΔVRi. Hemodynamic phenotype did not modify this association (p = 0.90). CONCLUSIONS: CRT changes are associated with vascular waterfall changes in post-cardiac surgery patients, primarily through the relationship with critical closing pressure rather than mean systemic filling pressure. These findings may provide a physiological framework for CRT-guided resuscitation and support its potential role as a bedside marker for assessing microcirculatory perfusion pressure.