Daily Anesthesiology Research Analysis

In 60 evaluable women undergoing elective cesarean delivery under spinal anesthesia, the estimated ED90 of the initial norepinephrine bolus followed by infusion was 0.157 μg/kg. Efficacy increased monotonically across doses from 0.13 to 0.19 μg/kg, with hypotension occurring in 12.2% of patients and relatively few adverse events.

Impact: The study provides a quantitatively defined prophylactic norepinephrine bolus dose for a common and clinically important complication of obstetric spinal anesthesia. Its double-blind dose-finding design offers a practical basis for protocol development and future adequately powered maternal-fetal safety trials.

Clinical Implications: An initial norepinephrine bolus of approximately 0.16 μg/kg followed by a titrated infusion may be considered when developing protocols to prevent postspinal hypotension during elective cesarean delivery. Local monitoring standards, vasopressor availability, and maternal-fetal safety data should guide implementation.

Future Directions: Larger multicenter trials should compare the approximately 0.16 μg/kg regimen with established phenylephrine or norepinephrine protocols and evaluate maternal symptoms, uteroplacental perfusion, neonatal outcomes, and safety across patients with varying cardiovascular reserve.

This multicenter randomized factorial feasibility trial enrolled 483 ASA physical status 3–5 patients undergoing major surgery and assigned them to different minimum mean arterial pressure targets or a baseline-based systolic pressure target. Target separation and adherence were adequate, but recruitment was lower than planned; higher MAP targeting was associated with more acute kidney injury, arrhythmias, and fewer days alive and out of hospital, findings requiring confirmation in larger trials.

Impact: The trial directly addresses a major unresolved question in perioperative medicine: how high intraoperative blood pressure should be targeted in high-risk patients. It demonstrates that protocol adherence and meaningful blood pressure separation are feasible, while its safety signals challenge the assumption that higher targets are necessarily beneficial.

Clinical Implications: The study supports the feasibility of individualized, protocolized intraoperative blood pressure targets but does not establish an optimal target. Clinicians should avoid automatically pursuing higher MAP targets until adequately powered outcome trials clarify the balance between renal, cardiac, and overall recovery outcomes.

Future Directions: A large, adequately powered multicenter trial should compare clinically justified blood pressure targets with high protocol adherence and prespecified renal, cardiac, neurologic, functional, and patient-centered outcomes.

Across 18 studies involving 2,313 patients, non-intubated video-assisted thoracoscopic lobectomy was associated with shorter operative and recovery-related times, shorter hospital stay, and fewer total complications, pneumonia cases, and sore throats than intubated surgery. Re-intubation occurred in 4.33% of NIVATS patients, while overall survival and recurrence-free survival were statistically better, although these findings may be influenced by selection bias and the predominance of nonrandomized evidence.

Impact: This synthesis evaluates a major shift in thoracic anesthesia and surgery: avoiding tracheal intubation during lobectomy. The findings suggest meaningful recovery and pulmonary benefits, but the long-term survival associations should be interpreted cautiously because most included evidence was observational.

Clinical Implications: NIVATS may be considered in carefully selected patients at experienced centers within enhanced recovery pathways. Implementation should include conversion criteria, airway rescue capability, patient selection protocols, and transparent discussion that long-term oncologic advantages remain uncertain.

Future Directions: Prospective multicenter trials should use standardized NIVATS protocols, predefined conversion and airway-safety endpoints, comprehensive adjustment for selection factors, and sufficiently long follow-up to determine whether apparent survival benefits are causal.