Daily Anesthesiology Research Analysis
Analyzed 28 papers and selected 3 impactful papers.
Summary
Three studies with direct relevance to anesthesiology and critical care stand out: a randomized trial demonstrates that remifentanil or dexmedetomidine attenuates extubation-related intracranial pressure surges after aneurysm embolization; a 14-year ECPR cohort defines long-term neurological outcomes and selection predictors; and a large ICU cohort shows that PK/PD-guided continuous piperacillin infusion with TDM improves target attainment and links exposure strata to mortality.
Research Themes
- Neuroanesthesia extubation strategies and noninvasive ICP monitoring
- ECPR patient selection and long-term neurological outcomes
- Precision antimicrobial dosing with PK/PD-guided TDM in the ICU
Selected Articles
1. Effect of different anesthesia strategies on intracranial pressure during extubation after intracranial aneurysm embolization: a randomized controlled trial.
In 63 patients randomized to remifentanil infusion, dexmedetomidine infusion, or control during extubation after aneurysm embolization, both drugs reduced ONSD/ETD (a surrogate for ICP), cough, HR, and MAP compared with control. Dexmedetomidine prolonged extubation time and increased bradycardia risk.
Impact: This pragmatic RCT provides actionable neuroanesthesia guidance for mitigating extubation-induced ICP surges using noninvasive monitoring, comparing two widely used agents with distinct hemodynamic profiles.
Clinical Implications: For neurointerventional cases, remifentanil infusion during extubation can blunt ICP surges without delaying extubation, while dexmedetomidine offers similar protection at the cost of bradycardia and longer extubation time. ONSD/ETD ultrasound can serve as a bedside adjunct to monitor ICP trends.
Key Findings
- Both remifentanil and dexmedetomidine groups had significantly lower ONSD/ETD at immediate and 5 minutes post-extubation versus control.
- Both drugs reduced moderate-to-severe cough, heart rate, and mean arterial pressure during extubation compared with control.
- Dexmedetomidine was associated with longer extubation time and higher bradycardia risk than control.
Methodological Strengths
- Prospective three-arm randomized controlled design
- Objective noninvasive ICP surrogate (ONSD/ETD) with serial time-point measurements
- Pre-registered clinical trial
Limitations
- Single-center study with a modest sample size (n=63)
- ONSD/ETD is a surrogate and not a direct ICP measurement
- Dexmedetomidine infusion timing may influence extubation readiness
Future Directions: Multicenter trials comparing dosing regimens and combinations (e.g., remifentanil plus lidocaine) with head-to-head ICP gold standards are needed to refine extubation protocols.
Intracranial pressure (ICP) fluctuations during the extubation period pose a risk of severe complications in patients undergoing intracranial procedures. Transorbital sonography was used to measure the ratio of optic nerve sheath diameter (ONSD) to eyeball transverse diameter (ETD), which has emerged as a novel non-invasive method for ICP monitoring. This study aimed to evaluate the effects of different anesthesia strategies on extubation-period ICP, using the ONSD/ETD ratio as a surrogate marker. This prospective randomized controlled trial enrolled 63 p
2. Long-term Neurological Outcomes After Extracorporeal Cardiopulmonary Resuscitation for Refractory Cardiac Arrest: A 14-Year Single-Center Cohort Study.
In a 14-year single-center ECPR cohort (n=295), 17.3% achieved favorable 6-month neurological outcomes (CPC 1–2), with IHCA outperforming OHCA. Younger age, initial shockable rhythm, and shorter low-flow duration independently predicted favorable outcomes; phenotype-based selection enriched good outcomes but risked excluding some potential recoverers.
Impact: Provides much-needed long-term neurological outcomes and empirically derived selection predictors for ECPR, informing activation criteria and resource allocation in cardiac arrest care.
Clinical Implications: ECPR activation protocols should prioritize patients with shorter low-flow times, younger age, and shockable rhythms, while balancing inclusivity to avoid excluding recoverable patients. Centers should track 6-month CPC to evaluate program effectiveness.
Key Findings
- Favorable 6-month neurological outcome (CPC 1–2) occurred in 17.3% overall, higher in IHCA (28.2%) than OHCA (10.1%; p<0.0001).
- Independent predictors of CPC 1–2: younger age (OR 0.95 per year), initial shockable rhythm (aOR 2.7), shorter low-flow duration (OR 0.95 per minute).
- Stepwise selection enriched favorable outcomes but risked excluding a small subset who might recover.
Methodological Strengths
- Large, 14-year consecutive single-center cohort with standardized outcome (6-month CPC)
- Multivariable and latent class analyses to identify independent predictors and phenotypes
Limitations
- Retrospective, single-center design with potential selection bias and unmeasured confounding
- Generalizability to other systems and ECPR protocols may be limited
Future Directions: Prospective multicenter registries to validate selection criteria and model-based, time-sensitive ECPR activation pathways; incorporation of neurologic prognostication biomarkers.
BACKGROUND: Extracorporeal Cardiopulmonary Resuscitation (ECPR) via Veno-Arterial Extracorporeal Membrane Oxygenation (ECMO) is a viable treatment for refractory cardiac arrest (r-CA). Data on long-term outcomes and predictors of favourable neurological prognosis remain limited, and definitive patient-selection recommendations are lacking. METHODS: We conducted a retrospective observational study of adult patients treated with ECPR for in-hospital (IHCA) and out-of-hospital (OHCA) r-CA at an Italian ECMO centre between 2011 and 2024. The primary outcome was long-term neurological performance, measured by the Cerebral Performance Category (CPC) scale six months after hospital discharge. Multivariable and latent class analyses assessed independent predictors and explored distinct pre-ECPR phenotypes. RESULTS: Among 295 consecutive patients (117 IHCA; 178 OHCA), 17.3% achieved CPC 1-2 at six months (28.2% IHCA vs 10.1% OHCA; p<0.0001), and 4.4% survived with severe long-term neurological sequelae (CPC 3-4). Independent predictors of CPC 1-2 were younger age (OR 0.95 per year, 95% CI 0.92-0.98), an initial shockable rhythm (aOR 2.7; 95% CI 1.11-7.04), and shorter low-flow duration (OR 0.95 per minute increase, 95% CI 0.93-0.97). Stepwise selection based on these criteria progressively increased the proportion of favourable survivors but excluded a small proportion who might have recovered. Conclusions These results emphasise the importance of establishing pre-treatment selection criteria to optimise ECPR use and enhance long-term neurological outcomes. Age, initial rhythm, and low-flow time are key determinants, and exploratory phenotype-based analyses suggest multidimensional patient characterisation may complement traditional selection criteria.
3. Pharmacokinetics, target attainment and outcomes of piperacillin/tazobactam in critically ill patients receiving continuous infusion with therapeutic drug monitoring: a retrospective analysis.
In 1,538 ICU patients receiving continuous piperacillin/tazobactam with PK/PD-guided dosing and TDM, therapeutic target attainment increased from 45.7% to 62.4% after TDM-guided adjustment. Supratherapeutic concentrations were associated with higher 28-day mortality, and women had greater odds of supratherapeutic exposure.
Impact: Demonstrates real-world feasibility and outcome associations of individualized PK/PD-guided beta-lactam dosing at scale, informing antimicrobial stewardship and precision dosing in critical care.
Clinical Implications: Adopt multimodal dosing (software-informed empiric dosing plus TDM) for piperacillin/tazobactam continuous infusion to maximize target attainment while avoiding supra-exposure, with attention to sex-related exposure differences.
Key Findings
- Target attainment within 32–64 mg/L rose from 45.7% at first measurement to 62.4% after TDM-guided adjustment.
- Supratherapeutic concentrations (>96 mg/L) were associated with higher 28-day mortality (40.9%) versus therapeutic (18.2%) and extended (27.0%) ranges.
- Women had 1.74-fold higher odds of supratherapeutic exposure compared with men.
Methodological Strengths
- Large real-world cohort (n=1538) with 3,089 TDM samples spanning 8 years
- Standardized individualized dosing software and protocolized TDM adjustments
Limitations
- Retrospective observational design with potential confounding by indication and illness severity
- Associations between exposure strata and mortality are non-causal and require prospective validation
Future Directions: Prospective interventional trials testing TDM targets and sex-specific dosing algorithms; integration with Bayesian adaptive dosing and MIC-informed stewardship.
OBJECTIVES: To provide real-world evidence on piperacillin exposure and outcomes in critically ill patients following the implementation of pharmacokinetic (PK)/pharmacodynamic (PD)-guided dosing in routine care. METHODS: This retrospective observational study included critically ill adults who received continuous piperacillin/tazobactam infusion between 2011 and 2019. Empiric doses were individualized using dosing software based on renal function and subsequently adjusted according to therapeutic drug monitoring (TDM) results. Drug exposure was defined as subtherapeutic (<32 mg/L), the