Weekly Anesthesiology Research Analysis
This week’s anesthesiology literature highlights a shift toward mechanism-driven therapeutics and pragmatic perioperative interventions. A randomized phase II trial identifies HIF1A stabilization (vadadustat) as a promising repurposed therapy for severe hypoxic SARS‑CoV‑2 lung injury. High-quality RCTs challenged common regional anesthesia choices—surgeon-performed intercostal blocks outperformed ESPB in uniportal VATS—and a large randomized trial linked tourniquet use to increased postoperative
Summary
This week’s anesthesiology literature highlights a shift toward mechanism-driven therapeutics and pragmatic perioperative interventions. A randomized phase II trial identifies HIF1A stabilization (vadadustat) as a promising repurposed therapy for severe hypoxic SARS‑CoV‑2 lung injury. High-quality RCTs challenged common regional anesthesia choices—surgeon-performed intercostal blocks outperformed ESPB in uniportal VATS—and a large randomized trial linked tourniquet use to increased postoperative delirium in older adults. Methodological and monitoring advances (time-based hs‑cTnT phenotypes, TEE-derived renal vein flow index, and statistical best-practices for ventilator-free days) also emerged with immediate clinical implications.
Selected Articles
1. Identification of HIF1A as a therapeutic target during SARS-CoV-2-associated lung injury.
Preclinical and clinical data link alveolar HIF1A biology to lung protection in SARS‑CoV‑2 infection. A multicenter, double‑blind phase II RCT (n=448) of the oral HIF stabilizer vadadustat showed on‑target gene induction, similar safety, and an overall modest reduction in severe lung injury at day 14; striking benefits were observed in the subgroup with baseline FiO2 ≥80%.
Impact: Connects mechanistic biology (HIF1A) with randomized clinical signal and suggests an orally available, repurposable therapy for severe hypoxic viral lung injury—potentially paradigm-shifting if confirmed in phase III.
Clinical Implications: Vadadustat and other HIF stabilizers merit larger confirmatory trials in pathogen-associated hypoxic pneumonia, with stratification by baseline hypoxemia severity; not ready for routine practice yet but justifies urgent phase III work.
Key Findings
- Vadadustat induced HIF target genes in patients and had similar safety to placebo in the phase II RCT.
- Overall estimated probability of severe lung injury at day 14: 13.3% (vadadustat) vs 16.9% (placebo); benefit was dramatic in patients with baseline FiO2 ≥80% (12.1% vs 79.1%).
- Preclinical murine and genetic models implicated alveolar Hif1a as mechanistically protective.
2. Erector Spinae Plane Block versus Intercostal Nerve Blocks in Uniportal Videoscopic-assisted Thoracic Surgery: A Multicenter, Double-blind, Prospective Randomized Placebo-controlled Trial.
A multicenter double‑blind RCT (n=100) found surgeon‑performed intercostal nerve blocks under direct thoracoscopic vision reduced 12‑ and 24‑hour morphine consumption, early pain scores, and rescue analgesic needs compared with ultrasound‑guided erector spinae plane block in uniportal VATS, with similar safety and shorter systemic local anesthetic exposure.
Impact: A high-quality head-to-head trial that challenges prevailing preference for ESPB in uniportal thoracic surgery and provides immediate guidance to favour surgeon-performed intercostal blocks for opioid-sparing analgesia.
Clinical Implications: Consider prioritizing thoracoscopically guided intercostal nerve blocks for uniportal VATS as first-line regional technique for opioid-sparing analgesia; monitor local anesthetic dosing and adopt ERAS‑consistent protocols.
Key Findings
- 12-h morphine consumption: 10.9 mg (intercostal) vs 17.6 mg (ESPB); P=0.0015.
- 24-h morphine consumption: 18.7 mg vs 26.7 mg; P=0.018.
- Lower early pain scores and fewer rescue analgesic needs (16% vs 40%) with intercostal block; similar satisfaction and length of stay.
3. Impact of tourniquet application on postoperative delirium in elderly patients undergoing total knee arthroplasty: a randomized clinical trial.
In a single‑center randomized trial of 313 older adults undergoing TKA, tourniquet use increased postoperative delirium within 7 days (19.1% vs 9.6%; P=0.018) and was associated with biomarker changes (↑HIF‑1α, ↓SOD) suggesting hypoxia/oxidative stress mechanisms; postoperative complications otherwise were similar.
Impact: Randomized evidence that a common intraoperative practice (tourniquet) increases delirium in older adults with mechanistic biomarker support—promptly actionable for orthopedic anesthesia protocols and delirium prevention bundles.
Clinical Implications: Minimize or avoid tourniquet use in elderly TKA when feasible, intensify delirium prevention measures, and consider interventions targeting hypoxia/oxidative stress in at‑risk patients; validate in multicenter settings.
Key Findings
- POD‑7 delirium: 19.1% (tourniquet) vs 9.6% (no tourniquet); RR 1.12; P=0.018.
- HIF‑1α increased at 30 min and 24 h; SOD decreased at 24 h in tourniquet group, suggesting hypoxia/oxidative stress.
- No significant difference in overall postoperative complications or adverse events.