The edition · Anaesthesiology
A normal MAP with a narrow pulse pressure is a low-flow state
Thirty thousand non-cardiac cases: pulse pressure under 40 mmHg raised postoperative kidney injury even when mean arterial pressure never dropped below 65, and stroke volume index in that group was 27 against 47. Plus COX-2 inhibitors measured on function rather than a pain score, and a new European guideline on anaesthetising inherited myopathies.
The edition in brief
The most useful finding today challenges the number most of us are watching. A retrospective cohort of 30,039 adult non-cardiac surgical patients from a South Korean academic centre stratified cases by median intraoperative pulse pressure — narrow below 40 mmHg, reference 40 to 70, wide above 70 — with entropy balancing for covariates including vasopressor load and hypotension duration. Acute kidney injury occurred in 6.7%. Narrow pulse pressure was independently associated with injury (odds ratio 1.66, 95% CI 1.42 to 1.94), and crucially, normotension with a narrow pulse pressure carried an odds ratio of 1.56, while hypotension with a normal pulse pressure did not raise risk at all (1.09, 0.86 to 1.38). A mechanistic substudy found stroke volume index of 27 mL/m² in the normotensive narrow group against 47 in the hypotensive reference group. Risk became significant after 40 minutes of exposure. A meta-analysis of 38 randomised trials and 5,424 patients measured perioperative selective COX-2 inhibitors against function rather than pain intensity, finding a Brief Pain Inventory interference reduction of 1.1 points, above the minimal clinically important difference, with lower intraoperative blood loss and no excess renal, gastrointestinal, cardiac or bone-healing events. A meta-analysis of 79 trials found remote ischaemic preconditioning did not reduce mortality overall but did in the subgroup preconditioned before induction. The European Malignant Hyperthermia Group has issued a consensus guideline on perioperative management of inherited skeletal muscle disorders.
Watching the mean arterial pressure alone hides the patients who go on to injure their kidneys
A pulse pressure under 40 mmHg raised postoperative acute kidney injury even with mean arterial pressure above 65 — a normal mean on vasopressor can mask a low-flow state.
COX-2 inhibitors measured on what patients can do, not on what they score
Perioperative selective COX-2 inhibitors cut pain interference with daily function by 1.1 points, above the clinically important threshold, with no excess renal, gastrointestinal, cardiac or bone-healing harm across 38 trials.
No new anaesthetic drug or device action; Europe issues consensus guidance on inherited myopathies
No new anaesthetic regulatory action today; the substantive change is a European consensus guideline that separates which inherited myopathies genuinely need a trigger-free anaesthetic from those that do not.
Remote ischaemic preconditioning failed overall — except when it was done before induction
Remote ischaemic preconditioning did not reduce mortality after non-cardiac surgery across 79 trials, and the positive result in those preconditioned before induction is a hypothesis, not a practice change.
Gastric ultrasound is widely studied and almost never studied for whether it changes anything
Only 2 of 65 gastric ultrasound studies examined whether the scan changed management, and none linked a change to a patient outcome — scan when the answer would alter your plan, and record the plan both sides of the scan.
Ask about the weekly injection, because the patient will not think to mention it
Ask every preoperative patient by name about weekly injections for weight or diabetes and when the last dose was — a standard fast does not reliably empty the stomach of someone taking one.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this one is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for anaesthesiology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free