Daily Anesthesiology Research Analysis
Analyzed 102 papers and selected 3 impactful papers.
Summary
Analyzed 102 papers and selected 3 impactful articles.
Selected Articles
1. Sevoflurane versus propofol and the long-term risk of attention-deficit/hyperactivity disorder in children.
In a 54,102-patient matched multinational cohort, sevoflurane as the primary pediatric anesthetic was associated with a higher long-term ADHD risk than propofol (HR 1.21). Findings were robust across extensive sensitivity analyses, suggesting anesthetic choice may influence neurobehavioral outcomes.
Impact: Addresses the long-standing question of pediatric anesthetic neurotoxicity with a large, rigorously matched, real-world cohort comparing specific agents.
Clinical Implications: For single-exposure pediatric anesthesia, consider propofol when feasible for maintenance/primary anesthetic to potentially mitigate long-term ADHD risk, while balancing surgical and airway needs; discuss potential long-term risks with caregivers. Prospective validation is needed before guideline changes.
Key Findings
- Among 54,102 matched children, cumulative ADHD incidence was 5.63% (sevoflurane) vs 2.95% (propofol).
- Sevoflurane exposure was associated with higher ADHD risk (HR 1.21; 95% CI 1.11–1.31).
- Robustness supported by propensity-score matching and multiple sensitivity/subgroup analyses.
Methodological Strengths
- Large, multinational EHR cohort with 1:1 propensity-score matching
- Extensive sensitivity and control analyses to address confounding
Limitations
- Observational design limits causal inference; residual confounding possible
- Outcome based on diagnostic codes; exposure misclassification cannot be excluded
Future Directions: Prospective, registry-based or randomized pragmatic studies assessing neurodevelopmental outcomes by anesthetic type; mechanistic biomarker and imaging studies to link exposure to neurodevelopmental trajectories.
BACKGROUND: Preclinical studies have shown that volatile anaesthetics, particularly sevoflurane, can disrupt neurodevelopment by inducing neuronal apoptosis, neuroinflammation and altered synaptic plasticity during critical periods of brain maturation. Whether these mechanisms translate into long-term neurobehavioral risk in children remains uncertain. AIMS: To compare the long-term risk of attention-deficit/hyperactivity disorder (ADHD) following paediatric anaesthesia with sevoflurane versus propofol in a large, multinational real-world cohort. METHODS: We conducted a large, multinational, retrospective cohort study using real-world electronic health record data from more than 150 healthcare organisations across North America, Europe and Asia. Children and adolescents (0-18 years) who underwent a single surgical procedure under general anaesthesia between 2005 and 2025 were included. Patients with ADHD or multiple anaesthetic exposures were excluded. The primary exposure was sevoflurane versus propofol as the main anaesthetic. The primary outcome was new-onset ADHD identified by International Classification of Diseases, Ninth or Tenth Revision codes after surgery. Propensity-score matching (1:1), subgroup, sensitivity and positive/negative control analyses were performed to ensure robustness. RESULTS: Among 54 102 matched children (27 051 per group), the cumulative incidence of ADHD was 5.63% after sevoflurane and 2.95% after propofol, corresponding to incidence rates of 134.9 and 105.4 per 10 000 person-years. Sevoflurane exposure was associated with a higher risk of ADHD (hazard ratio 1.21; 95% confidence interval 1.11-1.31; CONCLUSIONS: In this multinational cohort, sevoflurane exposure during paediatric anaesthesia was associated with an increased long-term risk of ADHD compared with propofol. These findings suggest that anaesthetic choice may have enduring neurobehavioral consequences and that prospective validation is warranted to guide safer paediatric anaesthesia practice.
2. Intraoperative allogeneic packed red blood cell transfusions and postoperative delirium: a retrospective cohort study in the USA.
Among 42,313 surgical patients, intraoperative PRBC transfusion was associated with a modest, dose-dependent increase in postoperative delirium risk, particularly when transfused at higher intraoperative hemoglobin nadirs; below 7.3 g/dL, no association was observed.
Impact: Quantifies a clinically actionable interaction between transfusion and hemoglobin nadir on delirium risk across a very large sample, informing intraoperative transfusion triggers.
Clinical Implications: Favor restrictive transfusion strategies intraoperatively, especially avoiding transfusion at higher hemoglobin nadirs (~≥7.3 g/dL), and enhance delirium prevention for transfused patients.
Key Findings
- Intraoperative PRBC transfusion increased postoperative delirium risk (aOR 1.15; 95% CI 1.03–1.29).
- Risk was dose-dependent and higher when transfusion occurred at higher intraoperative hemoglobin nadirs (P-interaction=0.002).
- No association between transfusion and delirium when hemoglobin nadir was <7.3 g/dL.
Methodological Strengths
- Very large single-center cohort with detailed intraoperative hemoglobin data
- Rigorous outcome ascertainment (codes, CAM, chart review) and interaction analysis
Limitations
- Retrospective single-center design; residual confounding cannot be excluded
- Transfusion indications and practices may vary and limit generalizability
Future Directions: Prospective trials or pragmatic studies to test delirium outcomes under different intraoperative transfusion thresholds; integrate delirium prevention bundles for patients requiring transfusion.
BACKGROUND: Delirium is a frequent and often detrimental postoperative complication that may be precipitated by perioperative inflammation. Packed red blood cell (PRBC) transfusions are important to maintain adequate oxygen delivery to ensure cerebral oxygenation, but can trigger inflammatory responses. This study aimed to evaluate the association between intraoperative PRBC transfusions, dependent on transfusion threshold and postoperative delirium. METHODS: This was a retrospective cohort study analyzing registry data from an academic tertiary-care center in Massachusetts, United States of America. Adult hospitalized patients who underwent general anesthesia for surgery between January 1, 2008 and January 15, 2024 with intraoperative hemoglobin measurements were included. Exclusion criteria included preoperative delirium or cognitive impairment, postoperative ventilation >72 h, an American Society of Anesthesiologists physical status >IV, and missing confounder data. The primary exposure was intraoperative allogeneic PRBC transfusions. The primary outcome was delirium diagnosed within seven days after surgery, identified through diagnostic codes, Confusion Assessment Method, and manual chart review. FINDINGS: Among 42,313 included patients, 6970 (16.5%) received intraoperative PRBC transfusions, and 2871 (6.8%) developed postoperative delirium. Patients receiving intraoperative PRBC transfusions had a higher risk of postoperative delirium (adjusted odds ratio 1.15, 95% confidence interval 1.03-1.29, P = 0.016) in a dose-dependent manner. The PRBC transfusion-associated risk of delirium was higher when intraoperative hemoglobin was at higher nadirs (P-for-interaction = 0.002). At nadirs below 7.3 g/dL, PRBC transfusions were not associated with delirium. INTERPRETATION: Intraoperative PRBC transfusions administered at higher hemoglobin nadirs, around 7.3 g/dL, were associated with an increased risk of postoperative delirium, suggesting that greater attention to delirium risk may be warranted among transfused patients and that transfusion triggers during surgery merit careful consideration. FUNDING: Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center.
3. High-frequency oscillation improves mucus clearance and airway resistance in mechanically ventilated patients: a randomized clinical trial.
In a randomized ICU trial (n=46), 10 minutes of CHFO plus suction versus suction alone significantly reduced airway resistance at 1 and 3 hours and improved compliance and dorsal ventilation distribution, indicating improved mucus clearance in ventilated patients with heavy secretions.
Impact: Provides randomized evidence for a practical, bedside adjunct that improves airway mechanics and ventilation distribution in a challenging ICU population.
Clinical Implications: Consider CHFO sessions as an adjunct to routine suctioning in ventilated patients with excessive secretions to reduce airway resistance and improve dorsal ventilation; standardize protocols and monitor mechanics and gas exchange post-intervention.
Key Findings
- CHFO significantly reduced airway resistance versus control at 1 hour (−2.4 vs −0.1 cmH2O/L·s; p<0.001) and 3 hours (−1.8 vs −0.5 cmH2O/L·s; p<0.05).
- Respiratory system compliance increased more with CHFO at 1 hour (4.9 vs 0.3 ml/cmH2O).
- Electrical impedance tomography indicated improved dorsal lung ventilation after CHFO.
Methodological Strengths
- Randomized controlled design with standardized ventilator settings and positioning
- Objective physiologic endpoints (Raw, Crs, EIT) at predefined timepoints
Limitations
- Single-center, small sample size limits generalizability
- Short follow-up (up to 3 hours); no clinical outcome endpoints (e.g., VAP, ICU LOS)
Future Directions: Multicenter RCTs powered for clinical outcomes (VAP, ventilator days, ICU LOS) and dose–response/optimal CHFO protocols; assess safety and effects in diverse ventilator modes.
BACKGROUND: Mechanical ventilation is associated with both impaired ciliary function and a weakened cough, which further impair secretion clearance. Continuous high-frequency oscillation (CHFO) is a promising technique to reduce respiratory muscle loading and facilitate secretion clearance in mechanically ventilated patients. The aim of this study was to assess the effect of CHFO on airway resistance (Raw). METHODS: This is a prospective, randomized controlled trial conducted in a 60-bed ICU between April 2023 and March 2024. Mechanically ventilated patients with excessive airway secretions (defined as the sputum volume exceeding 150 ml within the past 24 hours) were randomly assigned to either receive CHFO for 10 minutes followed by secretion aspiration (CHFO group), or to undergo secretion aspiration alone (control group). Throughout the study, only the study intervention and necessary suctioning were performed, and patient positioning and ventilator settings were kept constant. Arterial blood gases, respiratory mechanics, and the percentage of dorsal lung ventilation (assessed by electrical impedance tomography) were measured in both groups at four timepoints: pre-intervention (baseline), immediately post-intervention (T0), one-hour post-intervention (T1), and three-hours post-intervention (T3). The primary outcome was the change in Raw from baseline at each time point (ΔRaw: R RESULTS: 46 patients, with a median sputum volume of 160 ml over the last 24 hours, were enrolled. Baseline characteristics were well-balanced in the two groups. CHFO group showed a significantly larger decrease in Raw compared to control group at T1 (CHFO: -2.4 ± 1.8 vs. control: -0.1 ± 1.6 cmH₂O/L·s, p < 0.001) and T3 (CHFO: -1.8 ± 2.4 vs. control: -0.5 ± 1.9 cmH₂O/L·s, p < 0.05). Increase in Crs from baseline was greater in the CHFO group than control group at T1 (CHFO: 4.9 ± 8.8 vs. control: 0.3 ± 4.2 ml/cmH CONCLUSIONS: In mechanically ventilated patients with excessive airway secretions, the reduction in Raw from baseline was significantly greater in the CHFO group than control group at one-hour and three-hour post-intervention.