Weekly Anesthesiology Research Analysis
This week’s anesthesiology literature emphasizes perioperative hemodynamic management, precision physiologic modeling, and strategies that reduce immediate postoperative complications. High-quality randomized trials support prophylactic vasopressor use at induction to prevent hypotension and a large multicenter pediatric trial shows intravenous propofol maintenance reduces postoperative respiratory events. Complementary observational and modeling studies advance personalized haemodynamic targets
Summary
This week’s anesthesiology literature emphasizes perioperative hemodynamic management, precision physiologic modeling, and strategies that reduce immediate postoperative complications. High-quality randomized trials support prophylactic vasopressor use at induction to prevent hypotension and a large multicenter pediatric trial shows intravenous propofol maintenance reduces postoperative respiratory events. Complementary observational and modeling studies advance personalized haemodynamic targets and validate biomarkers and monitoring tools that can improve neuroprognostication and ventilatory-safety.
Selected Articles
1. Early Use of Norepinephrine in High-risk Patients Undergoing Major Abdominal Surgery: A Randomized Controlled Trial.
In a single-center randomized trial of older/high-risk patients undergoing major abdominal surgery, starting a titrated norepinephrine infusion at induction markedly reduced intraoperative hypotension and lowered 30-day composite medico-surgical complications compared with reactive ephedrine boluses. Pulmonary complications were also significantly reduced.
Impact: Provides high-quality randomized evidence that prophylactic, titrated vasopressor support at induction is an effective, scalable intervention to prevent postinduction hypotension and reduce short-term complications.
Clinical Implications: Consider protocolizing titrated norepinephrine infusion starting at induction for older or high‑risk major abdominal surgery patients to prevent hypotension and reduce pulmonary and composite complications; adapt institutional induction bundles accordingly.
Key Findings
- Titrated norepinephrine from induction reduced intraoperative hypotension versus ephedrine (15% vs 74%; P < 0.001).
- 30-day composite complications were lower with norepinephrine (44% vs 58%; RR 0.58; P = 0.004); pulmonary complications decreased (17% vs 31%; RR 0.46).
2. Effect of Intravenous, Inhalational, or Combined Anesthesia Maintenance on Postoperative Respiratory Adverse Events in Children Undergoing Adenotonsillectomy (AmPRAEC): A Multicenter Randomized Clinical Trial.
A multicenter RCT of >700 pediatric adenotonsillectomy patients found intravenous propofol maintenance produced the lowest incidence of postoperative respiratory adverse events in the PACU (IV 18.8% vs combined 28.5% vs inhalational 43.4%). Effect sizes were clinically meaningful (NNTs 3–7) supporting propofol infusion as preferred maintenance in this population.
Impact: Large multicenter pediatric RCT with pragmatic endpoints that can change anesthetic maintenance choices to reduce common, morbid postoperative respiratory events in children.
Clinical Implications: Prefer propofol infusion maintenance (or propofol-inclusive strategies) for pediatric adenotonsillectomy to reduce PRAEs; update PACU monitoring and training to support IV maintenance approaches.
Key Findings
- PRAE incidence: IV 18.8%, combined IV+inhalation 28.5%, inhalation 43.4%.
- Adjusted odds: IV vs IH aOR 0.25; IV vs IVIH aOR 0.57; NNTs ranged 3–7.
3. Higher vs standard mean arterial pressure target in the immediate postoperative period of liver transplantation to prevent acute kidney injury: A randomized clinical trial (LIVER-PAM).
In a randomized trial of post–liver transplant ICU patients, targeting MAP 85–90 mmHg for the first 24 hours did not reduce 7‑day AKI compared with 65–70 mmHg, though MAKE28 was lower in the higher MAP arm. Notably, biopsy-proven rejection requiring pulse therapy was more frequent with higher MAP, suggesting a trade-off.
Impact: A pragmatic RCT challenging the assumption that universally higher early MAP prevents AKI after liver transplant and revealing a potentially important adverse immunologic signal (increased rejection) that affects clinical targets.
Clinical Implications: Do not routinely escalate MAP to 85–90 mmHg solely to prevent early AKI after liver transplantation; maintain standard MAP goals (65–70 mmHg) and individualize hemodynamics while weighing potential MAKE benefits against increased rejection risk.
Key Findings
- No difference in 7‑day AKI: high MAP 69.7% vs standard 69.4% (RR 1.00; P = .97).
- MAKE28 lower with high MAP (56.1% vs 72.9%; RR 0.77); graft rejection requiring pulse therapy higher with high MAP (12.5% vs 3.5%; RR 3.54).