Daily Anesthesiology Research Analysis

BACKGROUND: Central venous catheterization (CVC) of the subclavian vein is a standard procedure in medicine. Ultrasound guidance is increasingly recommended to improve the success rates and reduce complications. This study compared the success rates and complications of ultrasound-guided microconvex in-plane subclavian puncture (MISP) with those of the landmark technique. METHODS: In this randomized controlled trial, 101 patients scheduled for elective surgery were enrolled and randomly assigned to either the group MISP or the control group using the landmark technique after ultrasound prescan. The primary end point was an a priori defined composite risk score including puncture attempts, required time, posterior venous wall injury, arterial punctures, hematoma formation, hemo-, pneumothorax, and catheter mispositioning. The secondary and exploratory end points included success rates, complication rates, and procedural times. Comparisons between groups were performed using Student t test, χ2 test, and Mann-Whitney U test with a significance level of 0.05. Data are mean ± standard deviation [SD], frequencies (%) or 95% confidence interval [CI] [lower limit-upper limit]). RESULTS: The mean ± SD composite risk score was significantly lower in the MISP group compared to control (6.4 ± 5.9 vs 11.6 ± 10.8; mean diff 5.21 [95% CI, 1.71-8.71], P = .028). The MISP technique demonstrated significantly higher as-treated overall success rates (86% [95% CI, 74.6%-93.9%] vs 71% [95% CI, 56.2%-82.5%], P = .046) and significantly reduced the risk of arterial punctures (1.9% [95% CI, 0.05%-10.45%] vs 12% [4.5%-24.3%], number needed to harm: 10 punctures, P = .047). One pneumothorax was noted in both groups (2% each). The mean procedural time was 5 minutes longer in the MISP group (P < .001). CONCLUSIONS: Compared with the landmark technique, the ultrasound-guided MISP technique significantly reduced the risk of complications. The extended procedural time may be justified by lower complication rates. Further studies should evaluate the implementation of the MISP technique as a standard approach for subclavian vein catheterization.

Remifentanil-induced hyperalgesia (RIH) complicates postoperative pain management under total intravenous anesthesia. Although monocyte transmigration contributes to neuropathic pain, its role in RIH remains undefined. Here, we investigated monocyte dynamics in RIH through preclinical and clinical studies. In male mice, intraperitoneal remifentanil infusion (4 μg/kg/min, 1 h) induced sustained mechanical hyperalgesia (reduced paw withdrawal thresholds, PWTs) over 48 hours, paralleled by a transient decline in circulating monocytes (3 h post-infusion) and increased macrophage infiltration in paw tissues. Critically, monocyte depletion significantly attenuated RIH, implicating monocytes in its pathogenesis. Translating these findings, a randomized trial of 44 patients undergoing minor surgery under sevoflurane-remifentanil anesthesia (0.3 μg/kg/min) revealed that perioperative flurbiprofen axetil (1 mg/kg) attenuated remifentanil-induced mechanical hyperalgesia (peri-incisional and upper limb regions) at 2 h and 24 h postoperatively (p < 0.05). Mechanistically, flurbiprofen axetil prevented remifentanil-driven reductions in circulating monocytes and suppressed plasma CCL3/G-CSF elevations (p < 0.05), despite unchanged monocytic COX-2 expression. In vitro, remifentanil (1000 ng/mL) directly promoted peripheral blood mononuclear cell migration (p < 0.05) without affecting viability. Collectively, monocyte transmigration underlies RIH in both animal models and humans, while flurbiprofen axetil counteracts hyperalgesia by retaining monocytes in circulation and modulating chemokine signaling. These translational insights highlight monocyte-targeted strategies as a therapeutic avenue for RIH. In this study, we demonstrated that extravascular migration of circulating monocytes is involved in remifentanil-induced hyperalgesia. Flurbiprofen axetil attenuates remifentanil-induced hyperalgesia, possibly by suppressing monocyte extravasation.

Intraoperative hypotension (IOH) is a frequent occurrence during noncardiac surgery. Hypotensive episodes can compromise tissue perfusion, and cumulative exposure has been associated with adverse outcomes such as acute kidney injury (AKI), myocardial injury, and increased mortality. The Hypotension Prediction Index (HPI) is an artificial intelligence tool designed to predict hypotensive events before they occur, allowing clinicians to intervene proactively to prevent or mitigate hypotension. Although randomized trials and pooled analyses have shown its effectiveness in reducing both the incidence and duration of IOH, its impact on patient-centered outcomes remains unclear. From 1946 to August 8, 2025, we prospectively queried MEDLINE (PubMed), Embase, Cochrane Library, and Web of Science. We included randomized controlled trials in adult surgical patients with invasive arterial monitoring, comparing HPI-guided perioperative hemodynamic management to standard care. Primary outcome was postoperative AKI, and secondary outcomes were postoperative myocardial injury, pneumonia, arrhythmia, stroke, postoperative cognitive dysfunction, including delirium, surgical site infection, length of hospital stay, and mortality. Two authors independently evaluated the risk of bias according to the methods described in the Cochrane Handbook for Systematic Reviews of Interventions. A meta-analysis was performed using RevMan 5.4.1 software. Dichotomous data were presented as risk ratio, 95% confidence interval [CI]; continuous data were presented as mean difference, 95% CI. All results were pooled using random-effects models. Of 883 imported references, 14 studies (N = 2030) were included for final analysis. No significant difference in incidence of postoperative AKI was observed between HPI-guided management and standard care, RR = 0.87, 95% CI (0.71-1.07). Postoperative myocardial injury was significantly reduced in HPI-guided management group, RR = 0.61, 95% CI (0.39-0.96), although exclusion-based sensitivity analysis suggests that this finding may not be robust. No other significant differences were observed for hospital length of stay, arrhythmia, stroke, cognitive dysfunction (including delirium), surgical site infection, pneumonia, or mortality. Although HPI-guided management is associated with a reduction in postoperative myocardial injury, its significance does not withstand sensitivity analysis. All other postoperative complications, including AKI incidence, are not reduced in the intervention groups. This study has limitations inherent to the heterogeneity of included patient populations, surgical interventions performed, standard of care practices, and reporting of postoperative outcomes.