BACKGROUND: The American Society of Anesthesiologists physical status (ASA-PS) is a grading system adopted worldwide by anesthesiologists to classify the overall health status of patients. Its importance is demonstrated not only by its routine use in clinical practice, but also by its deployment in other healthcare-related environments. However, a weak/moderate inter-rater reliability for ASA-PS has been previously shown, and although definitions and clinical examples of each class are provided by ASA, doubts remain on the individual factors influencing assignment to an ASA-PS class. The aim of this study was to investigate whether and how an anesthesiologist’s experience affects classification into a specific ASA-PS class. METHODS: An online survey presenting eight fictitious patients was administered to a group of Italian anesthesiologists and residents. Respondents were asked to assign each of the eight patients to a specific ASA-PS class. Anesthesiologists were subdivided into five classes according to years of experience as an anesthesiologist. RESULTS: Six hundred one surveys were correctly completed. The highest mean number of correct answers was obtained by residents (3.95 ± 1.13), with the number decreasing progressively with increasing work experience. The lowest value was recorded in the most experienced group (3.13 ± 1.25). Inter-rater reliability was weak/moderate in all experience level groups (k = 0.38). CONCLUSIONS: Low inter-reliability of the ASA-PS and the experience-dependence of the anesthesiologist in assigning classifications must be taken into account when evaluating a patient, particularly in settings where wide differences in experience are present.
Anesthesiology ; Classification ; Humans ; Surveys and Questionnaires

Intergroup comparability is of paramount importance in clinical research since it is impossible to draw conclusions on a treatment if populations with different characteristics are compared. While an adequate randomization process in randomized controlled trials (RCTs) ensures a balanced distribution of subjects between groups, the distribution in observational prospective and retrospective studies may be influenced by many confounders.
Propensity score (PS) is a statistical technique that was developed more than 30 years ago with the purpose of estimating the probability to be assigned to a group. Once evaluated, the PS could be used to adjust and balance the groups using different methods such as matching, stratification, covariate adjustment, and weighting. The validity of PS is strictly related to the confounders used in the model, and confounders that are either not identified or not available will produce biases in the results. RCTs will therefore continue to provide the highest quality of evidence, but PS allows fine adjustments on otherwise unbalanced groups, which will increase the strength and quality of observational studies.

Background: Hypocoagulability and impaired platelet function have been associated with a high risk of death in sepsis. The aim of this cohort study was to determine whether sepsis-induced hypocoagulability and platelet dysfunction (assessed by ROTEM® and MULTIPLATE®, respectively) are increased in sepsis patients who died within 28 days after diagnosis compared with patients who died between 29 and 90 days after diagnosis. Methods: Consecutive patients admitted to the intensive care unit of Padova University Hospital from March 2015 to March 2018 for severe sepsis were considered. We collected blood samples from all patients to determine ROTEM® and MULTIPLATE® parameters. Each enrolled patient underwent a 90-day follow-up and the mortality rate was recorded. Results: Of 120 patients, 36 (30%) died within 28 days post-diagnosis (Group A), 23 (19%) died between days 29 and 90 post-diagnosis (Group B), and 61 (51%) were alive after 90 days (survivors). The clotting time in the ROTEM® test and clot formation time in the EXTEM test were significantly more prolonged in Group A than in B. Both groups showed a significantly higher hypocoagulability than survivors in the EXTEM test. MULTIPLATE® platelet function analysis showed that platelet function was significantly lower in Group A than in Group B. Conclusions The present study showed that the combination of thromboelastometry and impedance aggregometry may help identifying sepsis patients at high risk of short-term death. Larger studies are warranted to corroborate our results.

Background: Trial sequential analysis (TSA) is a recent cumulative meta-analysis method used to weigh type I and II errors and to estimate when the effect is large enough to be unaffected by further studies. The aim of this study was to illustrate possible TSA scenarios and their significance using meta-analyses published in the Korean Journal of Anesthesiology as working material. Methods: We performed a systematic medical literature search for meta-analyses published in the Korean Journal of Anesthesiology. TSA was performed on each main outcome, estimating the required sample size on the calculated effect size for the intervention, considering a type I error of 5% and a power of 90% or 99%. Results: Six meta-analyses with a total of ten main outcomes were included in the analysis. Seven TSAs confirmed the results of the meta-analyses. However, only three of them reached the required sample size. In the two TSAs, the cumulative z-lines were not statistically significant. One TSA boundary for effect was reached with the 90% analysis, but not with the 99% analysis. Conclusions In TSA, a meta-analysis pooled effect may be established to assess if the cumulative sample size is large enough. TSA can be used to add strength to the conclusions of meta-analyses; however, pre-registration of the TSA protocol is of paramount importance. This study could be useful to better understand the use of TSA as an additional statistical tool to improve meta-analysis quality.

BACKGROUND: The American Society of Anesthesiologists physical status (ASA-PS) is a grading system adopted worldwide by anesthesiologists to classify the overall health status of patients. Its importance is demonstrated not only by its routine use in clinical practice, but also by its deployment in other healthcare-related environments. However, a weak/moderate inter-rater reliability for ASA-PS has been previously shown, and although definitions and clinical examples of each class are provided by ASA, doubts remain on the individual factors influencing assignment to an ASA-PS class. The aim of this study was to investigate whether and how an anesthesiologist’s experience affects classification into a specific ASA-PS class. METHODS: An online survey presenting eight fictitious patients was administered to a group of Italian anesthesiologistsand residents. Respondents were asked to assign each of the eight patients to a specific ASA-PS class. Anesthesiologists were subdivided into five classes according to years of experience as an anesthesiologist. RESULTS: Six hundred one surveys were correctly completed. The highest mean number of correct answers was obtainedby residents (3.95 ± 1.13), with the number decreasing progressively with increasing work experience. The lowest value was recorded in the most experienced group (3.13 ± 1.25). Inter-rater reliability was weak/moderate in all experience level groups (k = 0.38). CONCLUSIONS Low inter-reliability of the ASA-PS and the experience-dependence of the anesthesiologist in assigning classifications must be taken into account when evaluating a patient, particularly in settings where wide differences in experience are present.

Background: Trial sequential analysis (TSA) is a recent cumulative meta-analysis method used to weigh type I and II errors and to estimate when the effect is large enough to be unaffected by further studies. The aim of this study was to illustrate possible TSA scenarios and their significance using meta-analyses published in the Korean Journal of Anesthesiology as working material. Methods: We performed a systematic medical literature search for meta-analyses published in the Korean Journal of Anesthesiology. TSA was performed on each main outcome, estimating the required sample size on the calculated effect size for the intervention, considering a type I error of 5% and a power of 90% or 99%. Results: Six meta-analyses with a total of ten main outcomes were included in the analysis. Seven TSAs confirmed the results of the meta-analyses. However, only three of them reached the required sample size. In the two TSAs, the cumulative z-lines were not statistically significant. One TSA boundary for effect was reached with the 90% analysis, but not with the 99% analysis. Conclusions In TSA, a meta-analysis pooled effect may be established to assess if the cumulative sample size is large enough. TSA can be used to add strength to the conclusions of meta-analyses; however, pre-registration of the TSA protocol is of paramount importance. This study could be useful to better understand the use of TSA as an additional statistical tool to improve meta-analysis quality.

Background: While laparoscopic surgical procedures have various advantages over traditional open techniques, artificial pneumoperitoneum is associated with severe bradycardia and cardiac arrest. Dexmedetomidine, an imidazole derivative that selectively binds to α2-receptors and has sedative and analgesic properties, can cause hypotension and bradycardia. Our primary aim was to assess the association between dexmedetomidine use and intraoperative bradycardia during laparoscopic cholecystectomy. Methods: We performed a systematic review with a meta-analysis and trial sequential analysis using the following PICOS: adult patients undergoing endotracheal intubation for laparoscopic cholecystectomy (P); intravenous dexmedetomidine before tracheal intubation (I); no intervention or placebo administration (C); intraoperative bradycardia (primary outcome), intraoperative hypotension, hemodynamics at intubation (systolic blood pressure, mean arterial pressure, heart rate), dose needed for induction of anesthesia, total anesthesia requirements (both hypnotics and opioids) throughout the procedure, and percentage of patients requiring postoperative analgesics and experiencing postoperative nausea and vomiting and/or shivering (O); randomized controlled trials (S). Results: Fifteen studies were included in the meta-analysis (980 patients). Compared to patients that did not receive dexmedetomidine, those who did had a higher risk of developing intraoperative bradycardia (RR: 2.81, 95% CI [1.34, 5.91]) and hypotension (1.66 [0.92,2.98]); however, they required a lower dose of intraoperative anesthetics and had a lower incidence of postoperative nausea and vomiting. In the trial sequential analysis for bradycardia, the cumulative z-score crossed the monitoring boundary for harm at the tenth trial. Conclusions Patients undergoing laparoscopic cholecystectomy who receive dexmedetomidine during tracheal intubation are more likely to develop intraoperative bradycardia and hypotension.

Background: Different regional anesthesia (RA) techniques have been used for laparoscopic cholecystectomy (LC), but there is no consensus on their comparative effectiveness. Our objective was to evaluate the effect of RA techniques on patients undergoing LC using a network meta-analysis approach. Methods: We conducted a systematic review and network meta-analysis. We searched PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science (Science and Social Science Citation Index) using the following PICOS criteria: (P) adult patients undergoing LC; (I) any RA single-shot technique with injection of local anesthetics; (C) placebo or no intervention; (O) postoperative opioid consumption expressed as morphine milligram equivalents (MME), rest pain at 12 h and 24 h post-operation, postoperative nausea and vomiting (PONV), length of stay; and (S) randomized controlled trials. Results: A total of 84 studies were included. With the exception of the rectus sheath block (P = 0.301), the RA techniques were superior to placebo at reducing opioid consumption. Regarding postoperative pain, the transversus abdominis plane (TAP) block (−1.80 on an 11-point pain scale) and erector spinae plane (ESP) block (−1.33 on an 11-point pain scale) were the most effective at 12 and 24 h. The TAP block was also associated with the greatest reduction in PONV. Conclusions RA techniques are effective at reducing intraoperative opioid use, postoperative pain, and PONV in patients undergoing LC. Patients benefit the most from the bilateral paravertebral, ESP, quadratus lumborum, and TAP blocks.