Weekly Anesthesiology Research Analysis
This week’s anesthesiology literature highlights actionable randomized evidence and system-level signals. A large multicenter RCT found that driving pressure–guided high PEEP with recruitment maneuvers did not reduce postoperative pulmonary complications but increased intraoperative hypotension. Biomarker-guided precision immunotherapy for sepsis improved early organ dysfunction in a multinational RCT. Large observational data revealed concerning trends in TBI ICU mortality and rising withdrawal
Summary
This week’s anesthesiology literature highlights actionable randomized evidence and system-level signals. A large multicenter RCT found that driving pressure–guided high PEEP with recruitment maneuvers did not reduce postoperative pulmonary complications but increased intraoperative hypotension. Biomarker-guided precision immunotherapy for sepsis improved early organ dysfunction in a multinational RCT. Large observational data revealed concerning trends in TBI ICU mortality and rising withdrawal-of-life-sustaining-therapy rates, prompting ethics and quality-of-care reassessment.
Selected Articles
1. Intraoperative Driving Pressure-Guided High PEEP vs Standard Low PEEP for Postoperative Pulmonary Complications.
A large multicenter randomized trial (n≈1,435) compared a driving pressure–guided high PEEP strategy with recruitment maneuvers versus standard low PEEP in open abdominal surgery and found no reduction in a composite of postoperative pulmonary complications. High PEEP increased intraoperative hypotension and vasoactive use while low PEEP had more brief desaturation events. The trial supports avoiding routine use of individualized high-PEEP recruitment bundles for pulmonary complication prevention.
Impact: Definitive multicenter RCT evidence negating expected benefit of aggressive intraoperative high-PEEP recruitment strategies; directly informs ventilation protocols and guideline updates.
Clinical Implications: Do not routinely apply driving pressure–guided high PEEP with recruitment maneuvers for open abdominal surgery to prevent pulmonary complications; prioritize low tidal volume ventilation and assess PEEP individually considering hemodynamic tolerance.
Key Findings
- Primary composite pulmonary complications: 19.8% (high PEEP) vs 17.4% (low PEEP); no significant difference (P=0.23).
- High PEEP increased intraoperative hypotension (54.0% vs 45.0%) and vasoactive agent use (32.0% vs 18.8%).
- Low PEEP had higher incidence of brief intraoperative desaturation events (2.8% vs 0.8%).
2. Precision Immunotherapy to Improve Sepsis Outcomes: The ImmunoSep Randomized Clinical Trial.
In a multinational double-blind RCT of biomarker-stratified patients with sepsis, targeted immunotherapy (anakinra for macrophage activation-like syndrome; interferon-γ for sepsis-induced immunoparalysis) increased the proportion achieving ≥1.4-point SOFA reduction by day 9 versus placebo (35.1% vs 17.9%). No 28-day mortality benefit was observed; safety signals included anemia with anakinra and bleeding with interferon-γ. The trial operationalizes biomarker-driven host-directed therapy in sepsis.
Impact: Demonstrates feasibility and clinical signal for biomarker-guided host-directed immunotherapy in sepsis, potentially reframing trials and care pathways toward precision critical care.
Clinical Implications: For selected sepsis phenotypes, consider biomarker-guided immunomodulation in trial or protocolized contexts; require lab capacity (ferritin, monocyte HLA-DR), monitoring for anemia/bleeding, and integration with standard sepsis bundles.
Key Findings
- Primary endpoint: ≥1.4-point SOFA decrease by day 9 achieved in 35.1% (precision immunotherapy) vs 17.9% (placebo); difference 17.2% (P=.002).
- No statistically significant difference in 28-day mortality between groups.
- Safety signals: increased anemia with anakinra and increased hemorrhage with interferon-γ.
3. Hospital mortality, withdrawal of life-sustaining therapy decisions and early secondary brain insults for critically ill traumatic brain injury patients in England, Wales and Northern Ireland (2009-2024): an observational cohort study.
A 15-year, nationwide ICU cohort (45,684 TBI patients across 235 ICUs) reported rising hospital mortality (25.6% → 35.0%) and WLST decisions (7.5% → 19.7%) not seen in comparator cohorts. Exposure to early secondary brain insults, particularly hypoxemia, increased markedly. The findings raise questions about prognostication, care processes, and system-level drivers of outcomes in neurocritical care.
Impact: Large-scale, contemporary evidence identifying alarming, TBI-specific trends in mortality and WLST that have direct implications for neurocritical care quality, prognostication practices, and ethical frameworks.
Clinical Implications: Prioritize protocolized prevention of secondary brain insults (oxygenation, hemodynamics), implement standardized prognostication and multidisciplinary WLST frameworks, and audit system-level contributors to early hypoxemia and care variability.
Key Findings
- Hospital mortality increased from 25.6% to 35.0% over 2009–2024 among ICU TBI patients.
- WLST decisions rose from 7.5% to 19.7% over the same period; trends persisted after adjustment.
- Exposure to hypoxemia increased substantially (36.9% → 61.2%), with high frequencies of other early secondary insults.