Daily Anesthesiology Research Analysis
Analyzed 93 papers and selected 3 impactful papers.
Summary
Analyzed 93 papers and selected 3 impactful articles.
Selected Articles
1. General Anesthesia Versus Non-GA in Endovascular Therapy for Acute Ischemic Stroke: A Systematic Review and Bayesian Meta-Analysis of RCTs.
In a Bayesian meta-analysis of 10 RCTs (n=1,601), general anesthesia during endovascular thrombectomy showed a 94.2% posterior probability of improving 90-day functional independence and significantly higher reperfusion rates versus non-GA, without a clear mortality difference. GA increased intraoperative hypotension and possibly pneumonia, and heterogeneity of non-GA comparators and open-label designs warrant cautious interpretation.
Impact: This synthesis challenges prior conclusions of equivalence and provides probabilistic evidence favoring GA during EVT, with potential to inform stroke anesthesia protocols.
Clinical Implications: When institutional workflows support protocolized GA with vigilant hemodynamic management, GA may be preferred for EVT to enhance reperfusion and functional outcomes, while proactively mitigating hypotension and pulmonary complications.
Key Findings
- General anesthesia had a 94.2% posterior probability of superiority for 90-day functional independence (OR 1.24; 95% CrI 0.94–1.66).
- Successful reperfusion was significantly higher with GA (OR 1.73; 95% CrI 1.23–2.43; >99% probability of superiority).
- No substantial differences in 90-day mortality or symptomatic intracranial hemorrhage; GA increased intraoperative hypotension (OR 4.28) and pneumonia risk (OR 1.60).
Methodological Strengths
- PRISMA 2020–compliant systematic review of randomized trials with Bayesian random-effects modeling and weakly informative priors
- Comprehensive sensitivity analyses and meta-regression to probe heterogeneity
Limitations
- Open-label designs and heterogeneous non-GA comparators across trials
- Primary functional endpoint’s credible interval crossed 1.0 despite high posterior probability
Future Directions: Prospective, blinded, protocolized anesthesia RCTs in EVT with standardized hemodynamic targets and pulmonary complication mitigation could confirm causality and refine patient selection.
BACKGROUND AND OBJECTIVES: Endovascular thrombectomy (EVT) improves outcome in acute ischemic stroke (AIS) due to large vessel occlusion, yet the optimal anesthetic strategy remains controversial. Previous meta-analyses using frequentist methods reported no significant differences between general anesthesia (GA) and non-GA techniques; however, a recently published trial reported a high posterior probability of functional benefit with GA. We aimed to update the existing systematic review and to re-examine the cumulative randomized evidence using Bayesian statistical methods. METHODS: We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. PubMed/MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from inception to January 3, 2026, for randomized controlled trials (RCTs) comparing GA with non-GA strategies during EVT in adults with AIS. Primary outcomes were functional independence (modified Rankin Scale [mRS] 0-2) at 90 days, successful reperfusion (thrombolysis in cerebral ischemia 2b-3), and 90-day mortality. Bayesian random-effects meta-analyses with weakly informative priors were performed. Results are reported as odds ratio (OR) or mean difference (MD) with 95% credible intervals (CrIs). A posterior probability of superiority exceeding 80% was considered substantial evidence of benefit. Meta-regression and sensitivity analyses were conducted. RESULTS: Ten RCTs (n = 1,601; mean age 70.0 years; 46.6% female) were included. For functional independence, GA was associated with a 94.2% posterior probability of superiority (OR 1.24, 95% CrI 0.94-1.66). GA was associated with higher successful reperfusion rates (OR 1.73, 95% CrI 1.23-2.43; P (superiority) > 99%). No substantial differences were observed for 90-day mortality (OR 0.92, 95% CrI 0.67-1.27; P [superiority] 69%), excellent functional outcome (mRS 0-1; OR 1.06, 95% CrI 0.80-1.41; P [superiority] 67%), or symptomatic intracranial hemorrhage (OR 0.93, 95% CrI 0.56-1.52; P [superiority] 62%). GA was associated with increased intraoperative hypotension (OR 4.28, 95% CrI 2.35-7.86; P [superiority] 0.01%) and increased pneumonia risk (OR 1.60, 95% CrI 0.95-2.81; P [superiority] 3%). DISCUSSION: This meta-analysis using a Bayesian approach provides evidence that GA during EVT for AIS is associated with improved functional outcomes, challenging previous conclusions of equivalence. These findings should be interpreted considering open-label designs and heterogeneous non-GA comparators. They suggest that GA may be preferred but confirmatory evidence is needed.
2. Predicting Fluid Responsiveness in Mechanically Ventilated Adults: An Umbrella Review of Diagnostic Accuracy Meta-Analyses.
This umbrella review of seven diagnostic accuracy meta-analyses (123 studies; ~10,300 patients) found that tidal volume challenge and end-expiratory occlusion test provide the highest accuracy for predicting fluid responsiveness in mechanically ventilated adults, with PLR showing good accuracy and PPV/SVV only moderate. PVI and ΔIVC were least reliable and should not be used in isolation.
Impact: By clarifying comparative performance across dynamic tests, this synthesis can standardize bedside assessment strategies and reduce reliance on less reliable indices.
Clinical Implications: Prefer TVC and EEOT when ventilatory conditions allow; use PLR as an adjunct; interpret PPV/SVV with caution and avoid relying on PVI or ΔIVC alone for fluid decisions.
Key Findings
- Tidal volume challenge (AUC 0.96) and end-expiratory occlusion test (AUC 0.95) outperformed other indices.
- Passive leg raising had good accuracy (AUC ~0.91); PPV/SVV were only moderate (AUC ~0.87–0.88).
- PVI and ΔIVC were the least reliable (AUC ~0.82–0.83) and should not be used in isolation; tidal volume was a key effect modifier.
Methodological Strengths
- Umbrella review synthesizing multiple meta-analyses with overlap assessment (CCA, Jaccard)
- Extraction of pooled AUCs, sensitivity/specificity, with subgroup and meta-regression analyses
Limitations
- Findings depend on the quality and heterogeneity of included primary studies and meta-analyses
- Clinical applicability varies with ventilator settings, tidal volume, and sedation levels
Future Directions: Prospective head-to-head studies under standardized ventilatory conditions and pragmatic implementation trials could validate a streamlined fluid assessment algorithm centered on TVC/EEOT.
BACKGROUND: Dynamic indices and maneuvers are widely used to predict fluid responsiveness in mechanically ventilated patients, yet their relative performance remains uncertain. METHODS: We conducted an umbrella review of diagnostic accuracy meta-analyses published up to August 2025. Eligible reviews evaluated pulse pressure variation (PPV), stroke volume variation (SVV), passive leg raising (PLR), end-expiratory occlusion test (EEOT), tidal volume challenge (TVC), pleth variability index (PVI), or respiratory variation in inferior vena cava diameter (ΔIVC) in mechanically ventilated adults. Redundancy across reviews was assessed using the Corrected Covered Area (CCA), with pairwise overlap explored using Jaccard coefficients. The primary umbrella-level comparative metric was pooled area under the receiver operating characteristic curve (AUC) as reported by the included meta-analyses. Pooled sensitivity, specificity, and hierarchical ROC information were extracted when available. Secondary analyses included cumulative meta-analysis, subgroup and meta-regression analyses, prediction intervals, and assessment of small-study effects/publication bias. RESULTS: Seven meta-analyses were included, synthesizing 123 primary diagnostic studies and 10,300 patients. Global CCA was approximately 5.5% to 5.6%, consistent with borderline slight-to-moderate overlap across the included meta-analyses. TVC showed the highest comparative diagnostic performance (AUC 0.96, 95% CI, 0.94-0.97), followed by EEOT (AUC 0.95, 95% CI, 0.92-0.96). Passive leg raising (PLR) achieved good accuracy (AUC 0.91, 95% CI, 0.88-0.93), whereas pulse pressure variation (PPV) and stroke volume variation (SVV) showed only moderate performance (AUC 0.87-0.88). Pleth variability index (PVI) and inferior vena cava variation (ΔIVC) were the least reliable (AUC 0.82-0.83). Subgroup and moderator analyses indicated that tidal volume was the main effect modifier: TVC and EEOT remained comparatively robust. CONCLUSIONS: Among dynamic predictors of fluid responsiveness, TVC and EEOT appear to be the most accurate and robust indices. PLR retains intermediate utility, PPV and SVV show moderate reliability, whereas PVI and ΔIVC should not be used in isolation.
3. Neuromuscular Blockade Depth and Oculocardiac Reflex in Pediatric Strabismus Surgery: A Randomized Clinical Trial.
In a double-blind RCT of 201 pediatric patients, moderate-to-deep neuromuscular blockade reduced both the incidence (30.3% vs 53.9%; OR 0.37) and severity of the oculocardiac reflex during strabismus surgery compared with minimal-to-shallow blockade, and attenuated the reflex magnitude and duration among affected patients.
Impact: This trial provides actionable evidence that titrating to deeper neuromuscular blockade can mitigate a common, potentially hazardous reflex in pediatric ophthalmic surgery.
Clinical Implications: Consider targeting moderate-to-deep neuromuscular blockade with quantitative monitoring during extraocular muscle manipulation to reduce OCR risk, while ensuring timely and complete reversal to avoid residual paralysis.
Key Findings
- Moderate-to-deep blockade lowered OCR grade ≥2 incidence versus minimal-to-shallow blockade (30.3% vs 53.9%; OR 0.37; p=0.001).
- Severe OCR (grade ≥3) was reduced with deeper blockade (18.2% vs 35.3%; OR 0.41; p=0.007).
- Among those with OCR, deeper blockade attenuated both reflex magnitude and duration.
Methodological Strengths
- Prospective, double-blind randomized controlled design with quantitative neuromuscular monitoring
- Predefined, clinically meaningful OCR thresholds and adequate sample size
Limitations
- Single-center pediatric population limits generalizability to adults and other settings
- Specific anesthetic regimens and reversal protocols may influence external applicability
Future Directions: Multicenter trials across age groups and ophthalmic procedures should test generalizability and balance OCR reduction against recovery metrics and residual blockade risks.
BACKGROUND: Although neuromuscular blockade reduces oculocardiac reflex (OCR) incidence compared with no neuromuscular blockade, the effect of blockade depth on OCR has not been prospectively evaluated. This study aimed to evaluate whether the depth of neuromuscular blockade influences the incidence of the OCR during pediatric strabismus surgery. METHODS: In this prospective, double-blinded randomized controlled trial, 204 pediatric patients aged 3 to 18 years undergoing strabismus surgery under general anesthesia were randomly assigned to moderate-to-deep neuromuscular blockade (MD-NMB; train-of-four count 0-3) or minimal-to-shallow neuromuscular blockade (MS-NMB; train-of-four count 4 with ratio <0.9). The primary outcome was the incidence of OCR grade ≥2, defined as a ≥20% decrease in heart rate from baseline. Secondary outcomes included severe OCR (grade ≥3, defined as a ≥30% decrease in heart rate), as well as the magnitude and duration of heart rate reduction. RESULTS: A total of 201 patients were analyzed (MS-NMB, n=102; MD-NMB, n=99). The incidence of OCR grade ≥2 was lower in the MD-NMB group compared with the MS-NMB group (30.3% vs. 53.9%; odds ratio [OR] 0.37; 95% confidence interval [CI] 0.21-0.66; p = 0.001). OCR grade ≥3 was also reduced in the MD-NMB group (18.2% vs. 35.3%; OR 0.41, 95% CI 0.21-0.78; p = 0.007). Among patients who developed OCR, the magnitude (34.3% [26.9-42.6%] vs. 28.0% [18.2-35.9%]; p=0.003) and duration (46.0s [30.3-65.8s] vs. 37.0s [17.0-49.5s]; p=0.024) of heart rate reduction were smaller in the MD-NMB group. CONCLUSIONS: Moderate to deep neuromuscular blockade significantly reduced both the incidence and severity of OCR during pediatric strabismus surgery compared with minimal to shallow blockade. These findings suggest that deeper neuromuscular blockade may represent an effective strategy to attenuate OCR during extraocular muscle manipulation.