Abstract in English:

Abstract Background and objectives Video Laryngoscopy (VL) provides enhanced glottic visualization in airway management, but its high cost limits adoption. Three-Dimensional (3D) printing offers a cost-effective alternative for producing VL devices. This randomized trial compared a 3D-printed Videolaryngoscope (VL3D) with the standard Macintosh Laryngoscope (MAC) during tracheal intubation in adults. Methods This was a randomized, controlled, and assessor-blinded clinical trial. The primary outcome was intubation difficulty, assessed using the Intubation Difficulty Scale (IDS). Secondary outcomes included glottic visualization (Cormack-Lehane grade) and Intubation Time (IT). The final analysis followed a modified intention-to-treat principle. Results This study included 52 patients scheduled to undergo general anesthesia with tracheal intubation. Baseline characteristics were comparable between groups. The analysis included 49 patients (VL3D, n = 26; MAC, n = 23). Categorical analysis of the primary outcome showed a higher incidence of moderate-to-severe intubation difficulty in the VL3D group (23.1% vs. 0%, p = 0.032), although median IDS scores were statistically similar. In relation to secondary outcomes, the VL3D provided significantly superior glottic visualization (Cormack-Lehane grade I: 72.0% in the VL3D group vs. 33.3% in the MAC group, p = 0.002). Conversely, the VL3D was associated with a significantly longer intubation time (median 70 seconds vs. 40 seconds, p = 0.005). Conclusions The VL3D demonstrated superior glottic visualization but correlated with significantly longer intubation duration and greater procedural difficulty. These findings suggest that additional specialized training or design optimization is necessary before widespread clinical implementation.

Abstract in English:

ABSTRACT Background Supraglottic Airway Devices (SADs) are essential in airway management. However, little is known about their use, perceptions, and barriers in large, resource-variable healthcare systems such as Brazil. We aimed to assess current practice patterns, training exposure, and barriers to SADs use among Brazilian anesthesiologists and trainees. Methods A nationwide, web-based survey that addressed demographics, training exposure, device availability, frequency of use, perceived safety and efficacy, barriers to use, and knowledge of SADs generations. Descriptive and inferential statistics were used to analyze regional and experiential patterns. Results A total of 432 completed responses were analyzed. Most respondents were fully trained anesthesiologists (75.5%) from all five Brazilian regions. Although SADs were widely perceived as safe (76.9%) and capable of providing adequate ventilation (74.3%), only 35% reported using them at least once per week, and fewer than 20% felt confident distinguishing between first and second-generation devices. Binomial logistic regression revealed that greater training exposure during residency was strongly associated with more frequent current use (OR = 7.3; 95% CI 3.8‒14.3, p < 0.001). The most common barrier was lack of operator experience (81.5%), followed by limited availability of devices (28.9%). Use varied across regions (p < 0.001), with 82% of anesthesiologists in the South reporting weekly use compared to only 15.4% in the North. Respondents were more likely to use SADs in limb surgeries, while use is limited in gastrointestinal and thoracic procedures. Conclusions Despite favorable perceptions of safety and efficacy, SADs remain underused in Brazil, with marked regional variation and limited familiarity with device generations. Training exposure emerged as a strong predictor of current use, underscoring the importance of structured education and hands-on experience. Addressing gaps in training and improving device availability may help standardize practice and enhance the use of SADs across the country. Institutional Research Board approval n° 7.214.701; CAAE: 84060624.6.0000.8807.

Abstract in English:

Abstract Background The practice of immediate extubation in the Operating Room (OR) after cardiac surgery involving cardiopulmonary bypass remains debated. Concerns persist regarding its safety profile compared to conventional fast-track weaning in the Intensive Care Unit (ICU). Methods This retrospective analysis of a prospective single-center registry included 846 adult patients undergoing isolated Coronary Artery Bypass Grafting (CABG) or Heart Valve Surgery (HVS). To rigorously account for indication bias, we employed a doubly robust estimation approach, combining Stabilized Inverse Probability of Treatment Weighting (SIPTW) with multivariable regression adjustment for residual confounding. Results Of the 846 patients, 115 (13.6%) were extubated in the OR and 731 (86.4%) in the ICU. The weighted analysis successfully balanced baseline characteristics. Extubation in the OR was associated with a significant reduction in 30-day mortality (adjusted Hazard Ratio [aHR = 0.16]; 95% CI 0.03-0.92; p = 0.040) and acute kidney injury (adjusted Odds Ratio [aOR = 0.55]; 95% CI 0.31-0.99; p = 0.046). Additionally, it reduced the likelihood of prolonged ICU stay (> 14 days) (aOR = 0.10; p = 0.032). Contrary to unadjusted analyses, there was no significant association with respiratory tract infection (p = 0.163), reintubation (p = 0.103), or other adverse events. Conclusion In this single-center, robustly adjusted analysis, extubation in the OR was associated with favorable outcomes, including lower 30-day mortality and reduced resource utilization in highly selected patients. Previous concerns regarding increased reintubation rates were not substantiated.

Abstract in English:

Abstract Background Coronary Artery Bypass Grafting (CABG) in Jehovah’s Witness (JW) patients raises concerns regarding perioperative safety because of refusal of allogeneic blood transfusions. This study evaluated the feasibility and short-term outcomes of CABG in JW patients and described perioperative blood management practices. Methods This retrospective observational study included 26 JW patients and 78 matched non-Jehovah’s Witness (non-JW) patients who underwent CABG at InCor HC-FMUSP between 2015 and 2023. Propensity score matching at a 3:1 ratio based on age, sex, and preoperative hemoglobin was used to improve comparability. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 30-day stroke, myocardial infarction, and acute kidney injury; ICU length of stay; perioperative red blood cell transfusion rates; postoperative hemoglobin and hematocrit; intraoperative blood loss; and cardiopulmonary bypass time. Results No 30-day deaths occurred among JW patients, whereas three deaths occurred in the non-JW group (OR = 0.45; 95% CI 0.003-5.09; p = 0.575). No JW patient experienced stroke, and one myocardial infarction occurred. JW patients had higher postoperative hemoglobin (OR = 1.50; 95% CI 1.03-2.28; p = 0.032) and lower intraoperative blood loss (OR = 0.55; 95% CI 0.27-0.98; p = 0.046). No JW patient received transfusion, whereas 17.9% and 12.8% of non-JW patients required intraoperative and postoperative transfusions, respectively. ICU length of stay was similar between groups. Conclusion In this cohort, CABG in JW patients was feasible with acceptable short-term outcomes. Outcomes were generally comparable between groups, acknowledging imprecision related to the small JW sample.

Abstract in English:

Abstract Background The aim of this study was to evaluate the effectiveness of two general-purpose Large Language Models (LLMs), ChatGPT and Gemini, in predicting Intensive Care Unit (ICU) discharge decisions (discharge vs. non-discharge). By comparing their outputs with decisions made by ICU physicians, we sought to determine the alignment of AI-generated recommendations with expert clinical judgment and assess their potential as decision-support tools in critical care. Methods This prospective observational cohort study was conducted in a tertiary ICU between September 2024 and May 2025. Adult patients (≥ 18 years) requiring ICU discharge decisions were included. Standardized clinical prompts were generated from electronic health records and input into ChatGPT and Gemini. The models’ binary discharge decisions were compared to those of ICU physicians. Model performance was assessed using accuracy, sensitivity, specificity, F1 score, Cohen’s kappa, and McNemar’s test. Discharge was defined as the positive class for all diagnostic performance analyses. Results A total of 398 patients were analyzed. ChatGPT demonstrated higher accuracy than Gemini (87.2% vs. 66.3%), with higher sensitivity (85.9% vs. 46.9%) and F1 score (0.890 vs. 0.628), whereas Gemini showed higher specificity (96.2% vs. 89.2%). Agreement with clinician decisions was substantial for ChatGPT (κ = 0.737, p = 0.024) and fair for Gemini (κ = 0.379, p < 0.001). Laboratory markers such as lactate, hemoglobin, and procalcitonin significantly differed between discharged and non-discharged patients. Conclusion Large language models may support ICU discharge decisions when guided by structured, guideline-informed prompting. ChatGPT achieved higher overall accuracy, sensitivity, and F1 score, whereas Gemini demonstrated higher specificity. Trial registration Externation (Discharge) of ICU, NCT06584890, registered 03 September 2024, prospectively registered, https://register.clinicaltrials.gov/prs/beta/studies/S000EVXZ00000029/recordSummary.

Abstract in English:

Abstract Background Shoulder rotation and table tilt have been reported to increase the acoustic window for spinal ultrasonography. However, evidence in older adults remains scarce. This study evaluated their anatomical effects on lumbar (L3-L4) and thoracic (T10-T11) paramedian acoustic windows, quantified by posterior longitudinal ligament (PLL) length, in older adults (≥ 65 years). Methods This quasi-experimental study enrolled 45 older adults scheduled for elective surgery at two tertiary hospitals in Brazil. The primary outcome was PLL ultrasonographic length (paramedian sagittal oblique plane) assessed at the L3‒L4 and T10‒T11 interspaces in three positions: F (standard spinal flexion), S (F plus 45° leftward shoulder rotation), and T (F plus 10° dorsal table tilt). Data were analyzed using a Linear Mixed-Effects Model with Bonferroni-adjusted post-hoc contrasts. Results The model revealed significant effects of position (p = 0.003) and spinal level (p < 0.001) on PLL length, with no Level × Position interaction (p = 0.693). PLL length was significantly greater at L3-L4 than at T10-T11. Table tilt produced a significant increase relative to the flexion position (difference = 2.2 mm; 95% CI 0.9-3.5; p = 0.002), whereas shoulder rotation did not (difference = 1.2 mm; 95% CI 0.0-2.5; p = 0.158), with homogeneous effects across both levels. Fixed effects explained 27% of total variance (R2m = 0.27; R2c = 0.55). Conclusion Table tilt produced a significant anatomical enlargement of the neuraxial acoustic window at both spinal levels studied, whereas shoulder rotation did not reach statistical significance. These findings establish an anatomical foundation for future trials evaluating their impact on neuraxial procedural outcomes in older adults. Trial registration https://ensaiosclinicos.gov.br/rg/RBR-3p6t9pm.

Abstract in English:

Abstract Background Postoperative analgesia remains challenging in thoracic surgery, particularly with the rise of Robotic-Assisted Thoracoscopic Surgery (RATS). The Erector Spinae Plane Block (ESPB) is a promising opioid-sparing technique, but its role in RATS is unclear. Methods In this retrospective dual-center cohort study, we included 78 patients with lung cancer undergoing RATS, who received general anesthesia with or without ESPB. ESPB involved a single shot of 30 mL of 0.5% ropivacaine injection at T7, followed by a 24-hour infusion of 0.2% ropivacaine (7 mL.h⁻¹). The primary outcome was opioid rescue within 36 hours. Secondary outcomes included hospital length of stay and chest tube duration. Confounders were balanced with Inverse Probability Treatment Weighting (IPTW). Results In unadjusted analyses, there was no significant difference in rescue opioid consumption between groups (ESPB 37.8% vs. GA 27.3%; p = 0.46). After propensity score weighting to improve covariate balance, ESPB use was associated with lower postoperative opioid requirements (OR = 0.57; 95% CI 0.32-0.79; p = 0.01). This finding may reflect improved adjustment for measured confounders, although residual confounding cannot be excluded. In contrast, chest tube presence within 24 hours was associated with higher opioid requirements (OR = 2.32; 95% CI 1.22-4.20; p = 0.04). ESPB patients also required fewer scheduled opioids during the first 24-36h postoperatively (p = 0.03). Conclusion In this observational cohort, ESPB use was associated with lower postoperative opioid requirements in RATS. These findings suggest a potential role for ESPB within ERAS pathways, although randomized studies are needed to confirm efficacy and define its role in minimally invasive thoracic surgery.

Abstract in English:

Abstract Background Burnout syndrome is characterized by emotional exhaustion, depersonalization, and low personal accomplishment. Anesthesiology residents are particularly vulnerable due to prolonged working hours, cognitive overload, and exposure to stressful clinical situations. This study aimed to estimate the prevalence of burnout and explore associated occupational and psychosocial factors among anesthesiology residents in Rio Grande do Sul, Brazil. Methods This multicenter cross-sectional study included residents from 6 training centers accredited by the Brazilian Society of Anesthesiology. Data were collected using an anonymous online questionnaire and the Portuguese-validated Maslach Burnout Inventory-Human Services Survey (MBI-HSS). Burnout was defined by high emotional exhaustion (≥ 25), high depersonalization (≥ 10), and low personal accomplishment (≤ 32). Associations were analyzed using Fisher’s exact test (p < 0.05). Results Ninety-two residents participated (response rate, 84.4%). The overall prevalence of burnout was 26.1% (95% CI 17.5%-36.3%). High emotional exhaustion occurred in 72.8%, depersonalization in 42.4%, and low personal accomplishment in 43.5%. Burnout was significantly associated with living alone (p = 0.036) and psychotropic medication use (p = 0.017). A weekly workload of 60 hours or more (p = 0.068) was not significantly associated with burnout. Female residents showed higher emotional exhaustion (p = 0.039). Conclusion Burnout prevalence among anesthesiology residents in Rio Grande do Sul was high, predominantly characterized by emotional exhaustion. Institutional strategies focusing on psychosocial support, workload management, and mental health promotion may improve residents’ well-being and professional performance.

Abstract in English:

Abstract Background The main aim of this study was to compare the effects of propofol and sevoflurane induction on the echocardiographic parameters of Mitral Stenosis (MS) patients. Methods Prospective, randomized, outcome-assessor-blinded clinical trial in 80 adults with MS undergoing mitral valve replacement. Patients were randomized to receive General Anesthesia (GA) induction with either propofol (Group P) or sevoflurane (Group S). The primary objective was to assess the changes in mean gradient after 3 minutes of GA induction. Secondary objectives were to assess the changes in echocardiographic Doppler parameters and hemodynamic variables. Results Compared to pre-induction values, there was significant reduction in the peak and mean gradients as well as peak velocity, in both the groups after GA induction. The Mitral Valve Area calculated by continuity equation (MVA-c) and by pressure half time (MVA-p) were increased in Group S after GA induction. On comparison between the two groups, Group S showed lower pressure half time and greater MVA-p (p = 0.0099) and MVA-c (p = 0.0316) than Group P after GA induction. Mean arterial pressure decreased at the 1st and 3rd minute following GA induction in both groups. The Heart Rate (HR) increased at the 1st and 3rd minute in Group P whereas it reduced at both the time points in group S. Conclusion Even though both anesthetic agents reduced transvalvular gradients in MS patients, sevoflurane was associated with a greater increase in estimated valve area and a reduction in heart rate compared with propofol. These findings suggest more favorable short-term hemodynamic and echocardiographic changes with sevoflurane at the studied time points.

Abstract in English:

Abstract 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.

Abstract in English:

Abstract Background Programmed Intermittent Epidural Bolus (PIEB) and Continuous Epidural Infusion (CEI) are widely used strategies for maintaining postoperative analgesia, typically combined with Patient-Controlled Epidural Analgesia (PCEA). Although PIEB is theorized to enhance epidural drug distribution and analgesic effectiveness through intermittent high-pressure boluses, evidence supporting its superiority over CEI in the postoperative setting remains inconsistent. Methods We conducted a systematic review and meta-analysis of Randomized Controlled Trials (RCTs) comparing PIEB and CEI, both with PCEA, in adult postoperative patients (PROSPERO CRD420251046001). PubMed, Embase, and Cochrane were searched until May 1, 2025. Primary outcome: pain at 24 hours. Secondary outcomes: pain at other intervals, anesthetic consumption, and adverse events. Data were synthesized using a random-effects model; Risk of Bias (RoB-2) and small-study effects were assessed. Results Ten RCTs comprising 692 patients were included. No significant difference was found in 24-hour pain scores at rest (MD = -0.45; 95% CI -0.99 to 0.10) or movement (MD = -0.88; 95% CI -2.07 to 0.32). PIEB showed mildly lower pain at other time points and reduced total epidural volume (MD = -7.31 mL; 95% CI -13.7 to -0.92 mL). However, PIEB was associated with higher hypotension risk (RR = 1.71; 95% CI 1.05 to 2.78). No differences were found in opioid consumption, PCEA demands, or other adverse events. Conclusion PIEB offers no significant analgesic advantage and increases hypotension risk compared to CEI in postoperative settings, when both are combined with PCEA. These findings should be interpreted with caution due to the limited number of studies and substantial heterogeneity. PROSPERO registry https://www.crd.york.ac.uk/PROSPERO/view/CRD420251046001.

Abstract in English:

Abstract 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.