Weekly Anesthesiology Research Analysis
This week highlighted three actionable advances for perioperative care: a comprehensive NeuPSIG meta-analysis that refines first‑, second‑, and third‑line pharmacologic and neuromodulation recommendations for neuropathic pain; a large, externally validated TRANSFUSE prediction model that accurately forecasts intraoperative red blood cell transfusion and can reduce preoperative crossmatch waste; and a promising ropivacaine in situ gel that achieved multiday analgesia in preclinical models, offeri
Summary
This week highlighted three actionable advances for perioperative care: a comprehensive NeuPSIG meta-analysis that refines first‑, second‑, and third‑line pharmacologic and neuromodulation recommendations for neuropathic pain; a large, externally validated TRANSFUSE prediction model that accurately forecasts intraoperative red blood cell transfusion and can reduce preoperative crossmatch waste; and a promising ropivacaine in situ gel that achieved multiday analgesia in preclinical models, offering a potential single‑dose opioid‑sparing platform. Together these studies push practice toward more evidence‑based analgesic hierarchies, EHR‑driven risk prediction for resource stewardship, and new drug‑delivery technologies with clear perioperative implications.
Selected Articles
1. Pharmacotherapy and non-invasive neuromodulation for neuropathic pain: a systematic review and meta-analysis.
A preregistered NeuPSIG meta‑analysis of 313 double‑blind RCTs (48,789 adults) reappraises neuropathic pain treatments using RoB2 and GRADE, finding TCAs, α2δ‑ligands, and SNRIs offer the best first‑line balance of efficacy and harm (NNTs ~4.6–8.9), while opioids, BTX‑A, and rTMS are lower certainty and reserved as third‑line. Topical capsaicin 8% patches and other topicals hold weak second‑line roles. The work provides practical NNT/NNH estimates to guide anesthesia‑led pain services.
Impact: Comprehensive, high‑quality synthesis that clarifies benefit–harm tradeoffs across major pharmacologic and neuromodulatory options and is likely to change prescribing and referral patterns in perioperative/pain services.
Clinical Implications: Prioritize TCAs, α2δ‑ligands, and SNRIs as first‑line for neuropathic pain in perioperative and chronic pain pathways; reserve opioids, BTX‑A, and rTMS for refractory cases; use NNT/NNH to inform shared decision‑making and minimize opioid reliance.
Key Findings
- Synthesis of 313 randomized, double‑blind, placebo‑controlled trials encompassing 48,789 adults.
- First‑line efficacy: TCAs (NNT ~4.6), α2δ‑ligands (NNT ~8.9), SNRIs (NNT ~7.4) with acceptable NNHs.
- Opioids, botulinum toxin A, and rTMS had lower certainty evidence and were recommended as third‑line; capsaicin 8% and topical agents received weak second‑line status.
2. Development and Validation of a Risk Model to Predict Intraoperative Blood Transfusion.
The TRANSFUSE model was developed and externally validated across 816,618 surgical cases to predict intraoperative packed RBC transfusion using 24 preoperative variables (e.g., ASA status, INR, redo/emergency surgery, estimated duration ≥120 min, anemia). The model achieved AUC 0.93 with NPV 99.7% and outperformed an existing clinical score, enabling targeted preoperative crossmatch and blood‑management decisions.
Impact: Provides a high‑performance, transportable prognostic tool that can be implemented in EHRs to reduce unnecessary crossmatches and optimize blood product stewardship across surgical services.
Clinical Implications: Integrate TRANSFUSE into preoperative workflows/EHR decision support to right‑size crossmatch orders, prioritize blood conservation for high‑risk patients, and measure blood product savings and cost‑effectiveness prospectively.
Key Findings
- Model trained and validated on 816,618 surgeries with AUC 0.93 (95% CI 0.92–0.93).
- Included 24 preoperative predictors (ASA status, INR, redo/emergency surgery, duration ≥120 min, anemia, liver disease, thrombocytopenia, surgery type).
- Outperformed an established Transfusion Risk Understanding Scoring Tool (AUC 0.64) and matched/exceeded ML‑derived scores; NPV 99.7% overall.
3. An injectable in situ gel formed by ropivacaine with small lipid molecules to achieve long-term postoperative analgesia.
Preclinical formulation work combining a stearic acid–ropivacaine hydrophobic ion‑pair with glycerol monostearate produced an in situ gel (SA‑ROP‑GMS) that avoided burst release and delivered multiday analgesia (~10 days) in murine pain models without detectable systemic toxicity on histology/serum chemistry. The small‑molecule excipient profile suggests manufacturability and scalability.
Impact: Introduces a feasible, potentially low‑cost single‑dose local anesthetic depot that, if translated, could reduce opioid consumption, catheter need, and repeated dosing in perioperative practice — a potential paradigm shift for postoperative analgesia.
Clinical Implications: Requires GLP toxicology, large‑animal nerve block studies, and first‑in‑human PK/PD and safety trials before clinical adoption; if validated, could enable single‑shot blocks/wound infiltration for multiday analgesia and major reductions in opioid requirements.
Key Findings
- SA‑ROP‑GMS in situ gel avoided burst release and provided multiday (≈10 days) analgesia in mouse models after a single injection.
- Histology and serum biochemistry showed no systemic toxicity in treated animals.
- Formulation uses small‑molecule excipients with favorable manufacturability and cost profiles.