BACKGROUND:Airway manipulation during General Anesthesia (GA) can produce sympathetic activation and hemodynamic instability. Intravenous (IV) dexmedetomidine attenuates these responses but may cause bradycardia or hypotension. Intranasal (IN) administration is a noninvasive alternative with uncertain evidence in adults. We evaluated preoperative IN dexmedetomidine in adult patients undergoing GA. METHODS:We performed a PROSPERO-registered (CRD420251250492) systematic review and meta-analysis of randomized trials. MEDLINE, Embase, CENTRAL, and CDSR were searched from inception to November 26, 2025. IN dexmedetomidine versus control and IN vs. IV dexmedetomidine were assessed separately. Random-effects models pooled continuous outcomes as MDs/SMDs and adverse events as RRs. Risk of bias was assessed using RoB2 and certainty of evidence using GRADE. RESULTS:Across 25 trials including 1,968 patients, IN dexmedetomidine was associated with deeper sedation (SMD = 0.76; 95% CI: 0.18-1.34) and reduced heart rate and mean arterial pressure at induction, intubation, and during the early intraoperative period compared with control (MD range: -12.7 to -13.4 bpm and -7.8 to -10.7 mmHg, respectively). Rates of bradycardia and hypotension were similar between IN dexmedetomidine and control groups. Compared with IV dexmedetomidine, IN administration resulted in lighter sedation (SMD = -0.54; 95% CI: -1.08 to -0.01), with similar hemodynamic effects, while bradycardia and hypotension occurred less frequently. CONCLUSION:Preoperative IN dexmedetomidine may improve sedation and blunt peri-induction hemodynamic responses compared with controls, with broadly similar hemodynamic effects and fewer observed cardiovascular adverse events versus IV administration. However, certainty was low or very low for several efficacy outcomes, and larger well-designed trials are needed.
BACKGROUND:Postoperative Pulmonary Complications (PPCs) are a leading cause of morbidity, mortality, and prolonged hospitalization in surgical patients. Intraoperative mechanical ventilation plays a critical role in mitigating these risks, yet clinical practices remain heterogeneous and often not guided by evidence-based standards. OBJECTIVE:To develop evidence-based recommendations on perioperative mechanical ventilation strategies for surgical patients, aiming to optimize respiratory care, reduce PPCs, and standardize practice in Brazil. METHODS:This guideline was developed under the coordination of the Brazilian Society of Anesthesiology (SBA) by a panel of anesthesiologists and intensivists from multiple institutions. Seventeen clinical questions were structured in the PICO format (Population, Intervention, Comparison, Outcome). Systematic literature searches were conducted in PubMed, Embase, Cochrane Library, and Scopus up to July 2025. The strength of recommendations and certainty of evidence were assessed using the GRADE methodology. A modified Delphi process was applied to obtain agreement among collaborators, and consensus was discussed only when the predefined threshold of at least 80% agreement was not achieved. All recommendations were standardized in a uniform format. RESULTS:Seventeen thematic chapters were developed, covering topics from respiratory physiology and the definition of PPCs to advanced intraoperative monitoring, special populations (obese, pediatric, thoracic and cardiac surgery), and patients with or without acute lung injury. Key recommendations include the routine use of lung-protective strategies low tidal volumes of 6-8 mL.kg⁻¹ PBW in patients without ARDS and 4-8 mL.kg⁻¹ PBW in patients with ARDS, Positive End-Expiratory Pressure [PEEP] titrated to physiology, driving pressure ΔP ≤ 15 cm H2O, and Plateau Pressure [Pplat] ≤ 30 cm H2O), individualized approaches in high-risk patients, avoidance of unnecessary high fraction of inspired oxygen (FiO2), and selective use of recruitment maneuvers. Standardized definitions of PPCs and structured monitoring were emphasized as essential to improving patient outcomes. CONCLUSION:These consensus-based recommendations provide clinicians with a practical, evidence-informed framework for perioperative mechanical ventilation. Adoption of protective strategies and standardized definitions is expected to improve respiratory outcomes and reduce variability in perioperative care.
BACKGROUND:Enhanced Recovery After Surgery (ERAS) protocols have improved perioperative care across multiple surgical specialties. In obstetrics, ERAS pathways for cesarean delivery have been increasingly adopted; however, their comparative effectiveness versus standard care remains uncertain. Therefore, we conducted a systematic review and meta-analysis with trial sequential analysis to compare ERAS protocols with standard perioperative care in cesarean delivery. METHODS:We systematically searched MEDLINE, Embase, Web of Science, and Cochrane databases for Randomized Clinical Trials (RCTs) comparing ERAS and standard care in parturient undergoing cesarean delivery. Statistical analyses were performed using R software (version 4.2.2). We conducted subgroup analyses based on cesarean category (elective vs. emergency) and national income level. A Trial Sequential Analysis (TSA) was also performed. RESULTS:We included 13 RCTs comprising 1,809 parturient. ERAS was associated with a significant reduction in hospital Length of Stay (LOS) compared with standard care (MD = -17.05-hours, 95% CI -25.08 to -9.02 hours, I2 = 98.2%, n = 1,128, p < 0.01), with similar effects across elective and emergency cesarean deliveries. Greater reductions were observed in low- and middle-income countries, whereas no significant difference was identified in upper-middle-income settings, albeit formal subgroup test was not significant. ERAS was associated with lower postoperative pain at 24- and 48 hours, reduced wound infection, and higher maternal satisfaction, with no differences in readmission and postoperative nausea and vomiting. TSA suggested that the accrued sample size was adequate for hospital LOS; however, this should be interpreted cautiously given the substantial clinical and methodological heterogeneity. CONCLUSION:This systematic review and meta-analysis suggest that ERAS protocols may be associated with reduced hospital stay and improved maternal recovery after cesarean delivery.
BACKGROUND:Despite advances in patient blood management, the optimal hemoglobin threshold for Red Blood Cell (RBC) transfusion remains controversial. This observational study evaluated the association between the relative decline in Hematocrit (HCT) at the time of transfusion and postoperative outcomes in patients undergoing Coronary Artery Bypass Graft (CABG) surgery. METHODS:We conducted a retrospective cohort study of 629 patients who underwent CABG and received a transfusion at Tehran Heart Center Hospital, Iran, between March 2018 and December 2021. Based on the relative hematocrit reduction at the time of transfusion, patients were divided into two groups: Group A (≥ 40% change) and Group B (< 40% change). Early postoperative outcomes were compared between groups. Primary outcomes included mortality, hospital length of stay, intensive care unit length of stay, and intubation time. The composite secondary outcome comprised postoperative infection, renal failure, tamponade, and reoperation due to bleeding. RESULTS:There were no significant differences in primary outcomes, except hospital length of stay (p = 0.02). However, after adjustment for potential confounders, this difference was no longer significant (p = 0.32). Composite secondary outcomes were comparable between the two groups, with no significant difference observed (p = 0.85). CONCLUSION:In patients undergoing CABG surgery, this study did not identify a significant difference in early postoperative outcomes between two transfused patient groups stratified by a 40% change in HCT. Further prospective studies are needed to determine clinical relevance of relative hematocrit decline at the time of transfusion as a potential adjunct to conventional transfusion triggers. THC institutional review board: IR.TUMS.THC.REC.1402.070.
BACKGROUND:Effective communication and team non-technical skills are key points for patient safety in anesthesia and intensive care. Named caps have been proposed as a strategy to enhance team efficiency. However, evidence regarding their impact on objectively assessed team performance remains limited. METHODS:We conducted a prospective, single center, randomized, and experimental study in a high-fidelity simulation setting (SimHU, Nîmes). Anesthesia and intensive care residents, young doctors, and paramedics participated in simulated critical scenarios, alternating between sessions with and without named caps. The primary objective was to compare team performance, assessed by observers using the TEAM score. The secondary objectives were self-reported measures of entitativity, team cohesion and inclusion of self in the group. RESULTS:A total of 112 participants across 32 simulation sessions were included, which were assessed by 19 instructors. TEAM scores were significantly higher in the named cap group compared to the control group: the 44 points TEAM score (37 ± 7 vs. 33 ± 7; p = 0.026) and the total score (45 ± 8 vs. 40 ± 9; p = 0.020). Subjective perceptions of entitativity and team cohesion did not differ significantly. CONCLUSIONS:Named caps were associated with higher team performance in a simulated environment. Their impact on perceived team cohesion and entitativity was not statistically significant under simulation conditions. Further research in clinical settings is needed to determine whether named caps improve teamwork and patient safety.
BACKGROUND:Clonidine, an alpha-2-agonist, has several applications in pediatric anesthesia. Sympathetic nervous system-mediated pathways contribute to airway reactivity, suggesting that clonidine could mitigate respiratory adverse events similarly to more selective agents. METHODS:This was a post-hoc analysis of prospectively collected observational datasets from three research projects on children (1‒16 years) undergoing elective extracapsular (adeno-) tonsillectomies between January 2018 and November 2021. Patients' study data sheets and medical records were reviewed for clonidine use. The primary outcome was postoperative respiratory events (at emergence from anesthesia or in the post-anesthesia care unit). Post-anesthesia care unit length of stay was also monitored. RESULTS:The cohort consisted of 512 patients. The tonsillectomies were performed using coblation or electrocautery, local anesthetic infiltration; the airway was managed with a flexible supraglottic airway (97%). In the unadjusted cohort, postoperative respiratory events occurred in 44/306 children receiving clonidine (14%) and 50/203 children not receiving clonidine (25%) (OR = 0.616; 95% CI 0.361-1.047; p = 0.074). After propensity score matching, the between-group difference narrowed to 5 percentage points in the complete-case dataset and 4 percentage points in the multiply imputed dataset, with no statistically significant association between clonidine and postoperative respiratory events. Clinically, clonidine use did not prolong stay in PACU, 48.2 minutes (±22.5), compared with 50.0 minutes (±23.5). CONCLUSIONS:This post-hoc analysis found no statistical reduction in postoperative respiratory events associated with perioperative clonidine in pediatric patients following extracapsular (adeno)tonsillectomy and a flexible supraglottic airway. Clonidine use did not prolong time in PACU.
Background The impact of preoperative Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers (ACEI/ARB) on cardiac surgery-associated Acute Kidney Injury (AKI) remains elusive. We sought to evaluate the association of ACEI/ARB use with stage 2 or 3 AKI and in-hospital mortality, while evaluating whether preoperative withholding versus continuation strategies modulate clinical outcomes. Methods Multicenter prospective cohort study involving 14 Spanish and British hospitals. The study population comprised high-risk cardiac surgery patients (Cleveland Clinic Score ≥ 4). Results Among 249 patients (mean age: 69.5 years; 39% women; 53.8% ACEI/ARB users), the overall incidence of stage 2 or 3 AKI was 32.9%. ACEI/ARB use was associated with a significantly higher likelihood of stage 2 to 3 AKI (38.8% vs. 26.1%; adjusted OR = 2.79; 95% CI 1.47–5.30; p = 0.002). The adjusted risk difference was 0.188 (95% CI 0.079–0.298; p = 0.001), yielding a number needed to harm of 5.3. Sensitivity analyses confirmed the robustness of these findings, with an E-value of 2.73 (lower limit: 1.72) and consistent results using augmented inverse probability weighting (average treatment effect: 0.191; 95% CI 0.081–0.300; p = 0.001). No statistically significant associations were observed in in-hospital mortality or the impact of preoperative withholding versus continuation strategies on clinical outcomes. Conclusion This study suggests preoperative ACEI/ARB use may be associated with an increased incidence of stage 2 or 3 AKI. While differences in in-hospital mortality and preoperative withholding versus continuation strategies did not reach statistical significance, these findings reveal clinical trends that warrant further investigation.
BACKGROUND:Cardiac Arrest (CA) is considered a medical emergency and survival after CA is approximately 10%. Recognizing and providing effective intervention can have a significant impact on a patient's outcome. OBJECTIVE:To evaluate baseline knowledge of Cardiopulmonary Resuscitation (CPR) and the impact of a CPR training intervention to high school students in Aracaju, Sergipe. METHODS:This study was a pre-post educational intervention with 3-month follow-up involving 5 institutions that were chosen randomly from March to October 2023. The intervention was delivered in Portuguese, in four stages, aligned with the Kids Save Lives initiative: a pre-test was applied in 410 students before starting the course with questions regarding CPR and students' expectations; a theoretical-practical course was taught; after the course, students answered a post-test, an evaluation and satisfaction questionnaire. Finally, three months later, 343 students answered the post-test. RESULTS:The primary outcome was mean total score on a validated 14-item BLS knowledge test. We observed an increase in scores after training from 5.8 (2.2) pre-test to 10.9 (2.0) three months after. Scores decreased significantly from the immediate post-test to the 3-month follow-up, with a mean difference of 0.9 points (95% CI 0.61 to 1.13; Cohen's d = 0.354), but remained substantially higher than baseline. Self-perceived ability to perform CPR increased from 10.9% before training to 91% immediately after the course. CONCLUSION:Teaching CPR in educational institutions can improve CPR knowledge retention at 3 months following the intervention, supporting the feasibility of integrating similar programs in Brazilian schools and alignment with the trend of Brazilian education policies. INSTITUTIONAL RESEARCH BOARD APPROVAL:CAAE number: 57353622.0.0000.5546.
Background Red Blood Cell (RBC) transfusion in cardiac surgery is associated with risks. Conventional prediction scores lack accuracy, conflicting with Patient Blood Management (PBM) principles. Artificial Intelligence (AI) offers a potential avenue for developing precise, data-driven predictive models to enhance clinical decision-making and optimize patient outcomes. Methods A systematic review and meta-analysis of diagnostic test accuracy studies was conducted following PRISMA guidelines, searching PubMed, Embase, and Cochrane Library databases until April 2025. Studies developing AI models to predict intraoperative Red Blood Cell (RBC) transfusions in adult cardiac surgery were included. Pooled sensitivity, specificity, and Area Under the receiver operating Characteristic Curve (AUC) were calculated using a bivariate random-effects model. To summarize overall diagnostic performance, Summary Receiver Operating Characteristic curves were generated. Results Five studies encompassing 3,063 patients were analyzed in the meta-analysis. AI models demonstrated high pooled specificity, ranging from 86.3% (95% CI 82.8%‒89.1%) to 93.6% (95% CI 84.3%‒97.6%), whereas pooled sensitivity ranged from 50.3% (95% CI 20.9%‒79.6%) to 55.7% (95% CI 33.8%‒75.6%). AUC values ranged between 0.793 (95% CI 0.634‒0.899) and 0.892 (95% CI 0.740‒0.943). Preoperative hemoglobin levels and patient age were consistently identified as clinical predictors for intraoperative RBC transfusion. Conclusion This systematic review and meta-analysis suggests that AI models may have potential for predicting intraoperative RBC transfusion in cardiac surgery, with consistently high specificity but only moderate sensitivity. However, given the low certainty of evidence, substantial heterogeneity, and reliance on non-standardized transfusion practices, these findings should be interpreted cautiously.
