Weekly Anesthesiology Research Analysis
This week highlighted several high-impact, practice‑relevant anesthesiology findings: a large pragmatic RCT (IMPAKT ERAS) showed perioperative ketamine added to ERAS for major abdominal surgery provided no benefit and increased harms; a comprehensive meta-analysis supports routine use of upper‑airway point‑of‑care ultrasound to improve prediction of difficult laryngoscopy/intubation; and a randomized thoracic anesthesia trial found intraoperative lidocaine (IV or paravertebral) reduced major and
Summary
This week highlighted several high-impact, practice‑relevant anesthesiology findings: a large pragmatic RCT (IMPAKT ERAS) showed perioperative ketamine added to ERAS for major abdominal surgery provided no benefit and increased harms; a comprehensive meta-analysis supports routine use of upper‑airway point‑of‑care ultrasound to improve prediction of difficult laryngoscopy/intubation; and a randomized thoracic anesthesia trial found intraoperative lidocaine (IV or paravertebral) reduced major and pulmonary complications after lung resection, with cytokine reductions suggesting an anti‑inflammatory mechanism.
Selected Articles
1. IMpact of PerioperAtive KeTamine on Enhanced Recovery After abdominal Surgery (IMPAKT ERAS): a pragmatic randomised single-cluster trial.
In a pragmatic double‑blind randomized trial of 1,522 patients managed within ERAS for major abdominal surgery, perioperative ketamine (bolus + 48 h infusion) did not shorten hospital LOS or reduce opioid consumption versus placebo and was associated with higher ICU transfers and increased neuropsychiatric adverse events (dizziness, hallucinations). The data argue against routine ketamine inclusion in ERAS protocols.
Impact: Largest pragmatic trial to date testing ketamine in ERAS, providing definitive high‑quality evidence that routine perioperative ketamine confers no recovery benefit and carries measurable harms.
Clinical Implications: Avoid routine addition of perioperative ketamine within ERAS abdominal pathways; reserve ketamine for specific indications outside ERAS, and if used monitor for neuropsychiatric effects and increased ICU needs.
Key Findings
- No reduction in hospital length of stay with ketamine versus placebo (adjusted OR 1.21; 95% CI 1.00–1.47).
- No significant reduction in opioid consumption (OR 0.85; 95% CI 0.71–1.01).
- Increased ICU transfers (OR 2.03) and higher rates of debilitating dizziness (OR 6.05) and hallucinations (OR 2.69) with ketamine.
2. Point-of-care ultrasound of the upper airway in difficult airway management: a systematic review and meta-analysis.
A large systematic review and meta‑analysis of 60 studies (10,580 patients) found high pooled diagnostic accuracy for upper‑airway ultrasound metrics: skin‑to‑vocal‑cord distance predicted difficult laryngoscopy (sensitivity 0.84, specificity 0.81, AUROC 0.87) and skin‑to‑epiglottis distance predicted difficult intubation (sensitivity 0.80, specificity 0.86). Ultrasound also improved first‑pass success in percutaneous tracheostomy and cricothyroid membrane localization.
Impact: Consolidates a large evidence base supporting bedside airway ultrasound with quantifiable metrics—enables rapid translation into preoperative airway assessment algorithms and procedural planning.
Clinical Implications: Incorporate standardized upper‑airway ultrasound measurements (skin‑to‑vocal cord and skin‑to‑epiglottis distances) into difficult airway assessment protocols and use ultrasound guidance for cricothyroid localization and percutaneous tracheostomy to improve safety and first‑pass success.
Key Findings
- Skin‑to‑vocal cord distance: sensitivity 0.84, specificity 0.81, AUROC 0.87 for difficult laryngoscopy.
- Skin‑to‑epiglottis distance: sensitivity 0.80, specificity 0.86 for difficult intubation.
- Ultrasound improved first‑pass success in percutaneous tracheostomy and cricothyroid membrane identification versus palpation.
3. Effect of intraoperative paravertebral or intravenous lidocaine infusion on postoperative complications and inflammation after lung resection surgery: a randomised controlled trial.
In 154 VATS lung resection patients, intraoperative lidocaine infusion—administered either intravenously or via paravertebral catheter—reduced major (Clavien‑Dindo ≥III) complications (3.7–4.1% vs 11.8%) and pulmonary complications (22.3% vs 45.1%) compared with remifentanil, and attenuated bronchoalveolar/plasma cytokine elevations after one‑lung ventilation.
Impact: Randomized evidence linking an intraoperative anesthetic strategy (lidocaine infusion) to reduced hard postoperative outcomes and corroborating mechanistic cytokine data—immediately actionable for thoracic anesthesia practice.
Clinical Implications: Consider incorporating IV or paravertebral lidocaine infusion into multimodal thoracic anesthesia regimens to reduce major and pulmonary complications, with protocolized dosing and monitoring; re‑evaluate remifentanil‑based regimens when lidocaine is feasible.
Key Findings
- Major complications (Clavien‑Dindo ≥III) were lower with lidocaine (3.7–4.1%) vs remifentanil (11.8%); P=0.037.
- Pulmonary complications were reduced with lidocaine (22.3% vs 45.1%; OR 0.35; P=0.004).
- Post‑one‑lung ventilation cytokine levels in BAL/plasma were lower with lidocaine, consistent with an anti‑inflammatory effect.