Daily Anesthesiology Research Analysis
Analyzed 77 papers and selected 3 impactful papers.
Summary
Analyzed 77 papers and selected 3 impactful articles.
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 versus tapering alone. CBT may lower adverse events, including withdrawal symptoms. Findings support streamlined, patient-centered tapering while reserving behavioral resources for symptom mitigation.
Impact: Provides high-quality evidence clarifying that behavioral adjuncts do not increase long-term taper success, refining outpatient opioid deprescribing strategies.
Clinical Implications: Adopt patient-centered tapering with close monitoring as a first-line approach; consider CBT selectively to lessen withdrawal-related adverse effects rather than to boost taper success.
Key Findings
- Taper success at 12 months: 50.9% (taper only), 48.6% (taper+CBT), 44.5% (taper+CPSMP); no superiority of adjunct arms.
- Between-group differences in taper success: CBT vs taper only −2.4 percentage points (95% CI −11.9 to 7.2); CPSMP vs taper only −5.2 (95% CI −15.3 to 4.8).
- Adverse events (including withdrawal) highest with taper only (66%) vs CBT (54%) and CPSMP (64%).
Methodological Strengths
- Multicenter randomized controlled design across 11 sites with prespecified primary endpoint.
- Direct comparison of three pragmatic, patient-centered strategies with standardized definitions.
Limitations
- COVID-19 disruptions led to group imbalances, lower behavioral attendance, and attrition.
- Open-label design and potential contamination of co-interventions could affect generalizability.
Future Directions: Identify subgroups who benefit from behavioral adjuncts, enhance engagement (digital tools), and test stepped-care taper algorithms with patient-reported outcomes.
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. Dexmedetomidine for the prevention of postoperative atrial fibrillation: A systematic review and meta-analysis.
This systematic review and meta-analysis of 22 RCTs (n=4063) demonstrates that perioperative dexmedetomidine significantly reduces postoperative atrial fibrillation after cardiac surgery (RR≈0.80). Trial sequential analysis and GRADE suggest the finding is robust, supporting consideration of dexmedetomidine in anti-arrhythmic perioperative strategies.
Impact: Synthesizes randomized evidence with advanced methods (TSA, GRADE) to clarify dexmedetomidine’s anti-arrhythmic benefit in a common, morbid postoperative complication.
Clinical Implications: Consider dexmedetomidine as part of perioperative sedation/analgesia to mitigate POAF risk in cardiac surgery, with standard monitoring for bradycardia and hypotension and attention to optimal dosing and timing.
Key Findings
- Across 22 RCTs (n=4063), dexmedetomidine reduced POAF versus controls (RR ~0.80; 95% CI 0.70–0.93).
- Trial sequential analysis supported sufficiency of information size for the observed effect.
- Evidence certainty was graded using GRADE, reinforcing confidence in the POAF reduction signal.
Methodological Strengths
- Included only randomized controlled trials with random-effects modeling.
- Applied trial sequential analysis and GRADE to assess robustness and certainty.
Limitations
- Heterogeneity in dosing regimens, timing, and co-interventions across trials.
- Potential publication bias and variable POAF definitions or monitoring protocols.
Future Directions: Head-to-head, adequately powered trials to define optimal dosing and timing, evaluate sex-specific effects, and assess interactions with beta-blockers and anti-inflammatory strategies.
ObjectivePostoperative atrial fibrillation, a prevalent complication following cardiac surgery, significantly increases patient morbidity and healthcare expenditures. Although dexmedetomidine has been proposed as a potential strategy to mitigate the risk of postoperative atrial fibrillation risk, existing evidence from randomized controlled trials has shown conflicting results.MethodsTo evaluate the efficacy of perioperative dexmedetomidine in adult cardiac surgery patients, we conducted a systematic search across four major electronic databases: (a) PubMed; (b) Embase; (c) the Cochrane Library; and (d) Web of Science. Our search sought all relevant randomized controlled trials on this specific intervention and patient population. We utilized random-effects models to synthesize treatment effects, expressed as risk ratios with 95% confidence intervals. Furthermore, trial sequential analysis and the Grading of Recommendations Assessment, Development, and Evaluation framework were applied to determine the robustness and certainty of the evidence, respectively.ResultsOur analysis included 22 randomized controlled trials, involving a total of 4063 patients. Dexmedetomidine administration significantly lowered the risk of postoperative atrial fibrillation risk compared with control groups (risk ratio 0.80, 95% confidence interval: 0.70-0.93; I
3. A randomized, noninferiority clinical trial of Single-Shot Intrathecal Morphine versus Continuous Wound Infiltration for postoperative pain control after open pancreatoduodenectomy.
In an open-label noninferiority RCT after open pancreatoduodenectomy, single-shot intrathecal morphine (0.2 mg) was noninferior to continuous wound infiltration for overall coughing pain across 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.
Impact: Direct head-to-head randomized evidence in a high-risk abdominal surgery fills a key evidence gap on two widely used epidural alternatives.
Clinical Implications: Intrathecal morphine is a practical alternative to CWI with superior early analgesia after pancreatoduodenectomy; implement vigilant early monitoring for respiratory depression and pruritus.
Key Findings
- Primary outcome met: ITM noninferior to CWI for mean coughing pain at 24–72 h (mean difference −0.5; 95% CI −1.1 to 0.2).
- ITM achieved significantly lower pain at 2 h (rest and cough) with sustained cough-pain reduction at 24 h and reduced 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 prespecified 1.0 pain-score margin.
- Standardized multimodal analgesia and IV-PCA across groups.
Limitations
- Open-label, single-center trial with per-protocol primary analysis.
- Safety signal (early respiratory depression/pruritus) requires careful external validation.
Future Directions: Blinded, multicenter trials across abdominal procedures to confirm generalizability; dose–response optimization of intrathecal morphine and protocols for proactive side-effect monitoring.
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.