Mapping multicenter randomized controlled trials in anesthesiology: a scoping review.

BACKGROUND: Evidence suggests that there are substantial inconsistencies in the practice of anesthesia. There has not yet been a comprehensive summary of the anesthesia literature that can guide future knowledge translation interventions to move evidence into practice. As the first step toward identifying the most promising interventions for systematic implementation in anesthesia practice, this scoping review of multicentre RCTs aimed to explore and map the existing literature investigating perioperative anesthesia-related interventions and clinical patient outcomes. METHODS: Multicenter randomized controlled trials were eligible for inclusion if they involved a tested anesthesia-related intervention administered to adult surgical patients (≥ 16 years old), with a control group receiving either another anesthesia intervention or no intervention at all. The electronic databases Embase (via OVID), MEDLINE, and MEDLINE in Process (via OVID), and Cochrane Central Register of Control Trials (CENTRAL) were searched from inception to February 26, 2021. Studies were screened and data were extracted by pairs of independent reviewers in duplicate with disagreements resolved through consensus or a third reviewer. Data were summarized narratively. RESULTS: We included 638 multicentre randomized controlled trials (n patients = 615,907) that met the eligibility criteria. The most commonly identified anesthesia-related intervention theme across all studies was pharmacotherapy (n studies = 361 [56.6%]; n patients = 244,610 [39.7%]), followed by anesthetic technique (n studies = 80 [12.5%], n patients = 48,455 [7.9%]). Interventions were most often implemented intraoperatively (n studies = 233 [36.5%]; n patients = 175,974 [28.6%]). Studies typically involved multiple types of surgeries (n studies = 187 [29.2%]; n patients = 206 667 [33.5%]), followed by general surgery only (n studies = 115 [18.1%]; n patients = 201,028 [32.6%]) and orthopedic surgery only (n studies = 94 [14.7%]; n patients = 34,575 [5.6%]). Functional status was the most commonly investigated outcome (n studies = 272), followed by patient experience (n studies = 168), and mortality (n studies = 153). CONCLUSIONS: This scoping review provides a map of multicenter RCTs in anesthesia which can be used to optimize future research endeavors in the field. Specifically, we have identified key knowledge gaps in anesthesia that require further systematic assessment, as well as areas where additional research would likely not add value. These findings provide the foundation for streamlining knowledge translation in anesthesia in order to reduce practice variation and enhance patient outcomes.

Bilateral blood pressure differential as a clinical marker for acute aortic dissection in the emergency department.

INTRODUCTION: Interarm systolic BP differential is a classic sign of acute aortic dissection (AAD). All previous studies looking at the association of BP differential with AAD combine systolic BP differential >20 mm Hg with pulse deficit. Our aim was to assess the association of systolic BP differential with AAD, and its role in predicting AAD in the context of other signs and symptoms. METHODS: Historical matched case-control study using patient data collected between 2002 and 2014: participants were adults >18 years old with a bilateral BP measurement presenting to two tertiary care EDs or one regional cardiac referral centre in Canada. Cases were patients with diagnosed AAD; controls were those with a triage diagnosis of truncal pain (<14 days) and an absence of a clear diagnosis on basic investigation. Cases and controls were matched in a 1:1 ratio by sex and age. Bilateral BP differential and pulse deficit were compared between groups. RESULTS: A total of 222 patients (111 cases and 111 controls) were analysed. On univariate analysis systolic BP differential >20 mm Hg (OR 2.7, 95% CI 1.39 to 5.25) was significantly associated with AAD. Pulse deficit (diagnostic OR (DOR) 28.9) in isolation had better diagnostic accuracy than systolic BP differential >20 mm Hg in isolation (DOR 2.71) or combined with systolic BP differential >20 mm Hg (DOR 4.2). CONCLUSION: Bilateral systolic BP differentials >20 mm Hg are associated with non-traumatic AAD. However, the poor diagnostic accuracy and potential variability in measurement limits its clinical usefulness.