Daily Anesthesiology Research Analysis
Analyzed 80 papers and selected 3 impactful papers.
Summary
Today's most impactful anesthesiology research highlights methodological scrutiny of postoperative infection prediction models, evidence that intravenous lidocaine can substitute for adductor canal block after outpatient total knee arthroplasty, and large-scale safety data supporting perioperative ketorolac use without increased acute kidney injury risk. Collectively, these studies emphasize evidence calibration, pragmatic analgesic alternatives, and risk-stratified perioperative care.
Research Themes
- Validity and implementation of perioperative prediction models
- Opioid-sparing and pragmatic regional anesthesia alternatives
- Safety of multimodal analgesic strategies in patients with renal risk
Selected Articles
1. Efficacy of systemic lidocaine versus ultrasound-guided adductor canal block for patients undergoing total knee arthroplasty: a randomized, double-blinded, non-inferiority study.
In this randomized, double-blinded, non-inferiority trial of 120 outpatient total knee arthroplasty patients, intravenous lidocaine was non-inferior to a single-shot adductor canal block for 24-hour opioid consumption. The block provided better immediate post-anesthesia care unit analgesia, but pain, recovery quality, and satisfaction were otherwise similar, with no study-related adverse events.
Impact: This study provides pragmatic evidence for a non-regional analgesic option when nerve block expertise, time, equipment, or patient acceptance limits regional anesthesia. The non-inferiority design directly addresses a clinically relevant substitution question within an outpatient enhanced-recovery pathway.
Clinical Implications: Intravenous lidocaine can be considered an alternative analgesic strategy after outpatient total knee arthroplasty when an adductor canal block is impractical or contraindicated. Clinicians should recognize that adductor canal block may provide superior immediate recovery-room analgesia, despite comparable 24-hour opioid outcomes.
Key Findings
- Median 24-hour opioid consumption was 57.5 mg OME with lidocaine and 52.5 mg OME with adductor canal block; the 5.0 mg difference was within the prespecified non-inferiority margin.
- Adductor canal block reduced immediate post-anesthesia care unit opioid consumption and pain scores compared with lidocaine.
- Time to first analgesic request, quality of recovery, patient satisfaction, and adverse events were comparable between groups.
Methodological Strengths
- Randomized, double-blinded, non-inferiority design with a prespecified clinically interpretable opioid margin.
- Sham block and saline infusion supported blinding and reduced procedural expectation bias.
- The study was conducted within a standardized Enhanced Recovery after Surgery pathway.
Limitations
- The sample size was modest and the study may not detect uncommon adverse events or differences in functional recovery.
- Findings may not generalize to inpatient or complex total knee arthroplasty populations.
- The trial evaluated a single lidocaine infusion strategy and may not define optimal dosing or monitoring.
Future Directions: Larger multicenter trials should evaluate intravenous lidocaine in diverse arthroplasty pathways, including patients unable to receive regional anesthesia, and should assess mobilization, unplanned admission, longer-term recovery, and cost-effectiveness. Dose-optimization and safety-monitoring studies are also warranted.
BACKGROUND: Total knee arthroplasty (TKA) is associated with significant postoperative pain; therefore, adductor canal block is commonly used as part of multimodal analgesia. Intravenous lidocaine may provide a practical alternative when regional anesthesia is not feasible. This study compared intravenous lidocaine with ultrasound-guided adductor canal block for postoperative opioid consumption, pain scores, and quality of recovery within the first 24 hours after outpatient TKA. METHODS: In this non-inferiority trial, 120 patients undergoing TKA were randomized 1:1 to receive either a single injection adductor canal block with saline infusion or intravenous lidocaine infusion with sham block. The primary outcome was opioid consumption 24 hours after surgery, with a prespecified non-inferiority margin of 30 mg oral morphine equivalents (OME). Secondary outcomes included pain scores, time to first analgesic request, quality of recovery, and patient satisfaction.
2. Predicting postoperative infections: prediction models and their evaluation: A systematic review.
This systematic review evaluated 151 studies involving 267 postoperative infection prediction models and 314 validation analyses. No study reported clinical implementation, and the most frequently validated tools showed only modest and highly variable discrimination, with most studies judged to have high risk of bias.
Impact: The paper challenges the assumption that widely used perioperative infection calculators are ready for routine personalized decision-making. It identifies a major translational gap between model development and clinical implementation, directly informing future anesthesiology, perioperative medicine, and quality-improvement research.
Clinical Implications: Existing postoperative infection calculators should not be used as definitive decision tools without assessing calibration, transportability, and local performance. Clinical implementation should await better external validation, transparent reporting, impact analysis, and prospective evaluation of whether model-guided care improves outcomes.
Key Findings
- The review included 151 studies describing 267 distinct prediction models and 314 validation analyses.
- No included study assessed implementation of a postoperative infection prediction model in clinical practice.
- Reported discrimination was generally modest and highly variable; most studies had high risk of bias.
Methodological Strengths
- Broad searches of PubMed, Embase, and the Cochrane Library covered model development, validation, and implementation.
- The review assessed both predictive performance and methodological risk of bias rather than relying on model discrimination alone.
Limitations
- The review synthesized heterogeneous prediction models, outcomes, populations, and validation methods.
- Many primary studies had high risk of bias, limiting certainty about comparative model performance.
- The review could assess reported implementation evidence but could not establish whether individual models improve patient outcomes.
Future Directions: Future studies should use transparent reporting standards, independent external validation, calibration assessment, decision-curve analysis, and prospective impact studies. Research should prioritize implementation-ready models that demonstrably change perioperative decisions and improve patient outcomes.
BACKGROUND: Pre-operative assessment for postoperative infection risk helps identify patients for personalised decision-making and management. OBJECTIVE: This systematic review evaluates existing prediction models for infection, focusing on their validation and implementation status. DATA SOURCES AND ELIGIBILITY CRITERIA: PubMed, Embase and the Cochrane Library were searched for studies on the development, validation- and implementation of multivariable models utilising pre-operative predictors to estimate the risk of postoperative infections within 30-days of elective, major noncardiac, non-intracranial surgery. RESULTS: Of 151 included studies, 88 reported model development (267 distinct models), 88 assessed model validity (314 validation analyses), and none described implementation. Models predominantly predicted surgical site infections (SSI, n = 88), pneumonia (n = 45) and general (unspecified) infections (n = 57). Age (66%), sex (53%) and ASA score (48%) were the most common predictors. The American College of Surgeons Surgical Risk Calculator (ACS SRC) and SUrgical Risk Pre-operative Assessment System (SURPAS) were most frequently validated, with 225 and 35 external validations respectively.
3. Safety of Ketorolac in Primary Total Hip Arthroplasties: An Analysis of over 7,000 Cases.
In a retrospective analysis of 7,211 primary inpatient total hip arthroplasties, perioperative ketorolac was not associated with increased in-hospital acute kidney injury, regardless of whether it was administered intravenously or by periarticular infiltration. The absence of increased risk persisted in patients with chronic kidney disease, although chronic kidney disease itself was a strong risk factor for acute kidney injury.
Impact: This large real-world study addresses a common barrier to opioid-sparing multimodal analgesia: concern that ketorolac may cause renal injury after arthroplasty. The findings support more nuanced, risk-stratified use rather than blanket avoidance, while preserving the need for renal and hemodynamic monitoring.
Clinical Implications: Perioperative ketorolac may be considered for opioid-sparing analgesia after primary total hip arthroplasty, including selected patients with chronic kidney disease, when dosing, volume status, blood loss, and renal function are carefully monitored. Clinicians should not interpret the findings as proof of safety in severe renal failure or in unstable patients.
Key Findings
- Among 7,211 total hip arthroplasties, acute kidney injury occurred in 3.4% of cases.
- Perioperative ketorolac was not associated with increased acute kidney injury risk overall or by administration route; in patients without chronic kidney disease, use was associated with lower observed risk.
- Chronic kidney disease was an independent acute kidney injury risk factor, with additional risks associated with transfusion, new-onset atrial fibrillation, hypertension, male sex, and higher body mass index.
Methodological Strengths
- Large cohort of 7,211 arthroplasty cases with standardized Kidney Disease: Improving Global Outcomes criteria for acute kidney injury.
- Multivariable adjustment and subgroup analyses examined baseline chronic kidney disease and ketorolac administration route.
- The study addresses both intravenous and periarticular infiltration use in routine clinical practice.
Limitations
- The retrospective observational design cannot establish that ketorolac prevents acute kidney injury or eliminate residual confounding by indication.
- Ketorolac exposure was not randomized, and dosing patterns and perioperative fluid or hemodynamic management may have varied.
- The findings may not apply to severe renal failure, emergency surgery, outpatient arthroplasty, or highly unstable patients.
Future Directions: Prospective comparative studies should evaluate ketorolac dosing, route, renal-function thresholds, fluid-management protocols, and patient-centered outcomes in patients with chronic kidney disease. Pragmatic trials could define which high-risk subgroups benefit from ketorolac while minimizing renal and bleeding complications.
BACKGROUND: Ketorolac is commonly utilized perioperatively in primary total hip arthroplasty (THA), either intravenously (IV) or via periarticular infiltration analgesia (PAI). While effective for pain control, concerns remain regarding its potential to cause acute kidney injury (AKI), particularly in patients who have chronic kidney disease (CKD). This study evaluated the association between perioperative ketorolac administration and postoperative AKI, stratified by baseline renal function and administration route. METHODS: We retrospectively analyzed 7,211 inpatient THAs performed between 2011 and 2021. An AKI was defined according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regressions evaluated the association between perioperative ketorolac administration and in-hospital AKI, adjusting for demographic and clinical covariates. Subgroup analyses were conducted for patients who had (15%) and did not have (85%) preexisting CKD. Ketorolac was administered perioperatively in 35% of cases.