Nitrous Oxide (N2O) is a potent greenhouse gas with significant environmental impact and is currently the leading ozone depleting substance in use. Despite its long-standing role in anesthetic practice, data on N2O use and the environmental awareness of Brazilian anesthesiologists are scarce. This study aimed to describe patterns of N2O use and assess the level of awareness among anesthesiologists regarding its environmental impact. A nationwide cross-sectional survey was conducted among anesthesiologists in a private Brazilian hospital network. The questionnaire addressed the frequency of N2O use in adult and pediatric anesthesia, knowledge of its environmental effects, and attitudes toward its continued availability. Of 1,238 eligible anesthesiologists, 941 completed the survey (response rate 76%). Overall, 59.3% (n = 558) reported never using N2O in adult patients, while 14.5% (n = 136) reported frequent or constant use. In pediatric patients, 27.5% (n = 259) reported never using N2O, and 38.9% (n = 366) reported frequent or constant use. Eighty percent (n = 753) indicated a reduction in N2O use since the beginning of their careers, and 34.5% (n = 325) were unaware of its contribution to climate change. Age and years of professional experience were directly proportional to N2O use in adults (p < 0.05), while awareness of its environmental impact was inversely associated with use in pediatric cases (p < 0.05). The survey demonstrates a shift toward reduced N2O use, particularly among younger anesthesiologists, although substantial use in adult practice remains. Persistent knowledge gaps highlight the importance of targeted education and policy interventions to mitigate environmental impact.
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Opioid Epidural Labor Analgesia (OLEA) is commonly used during labor. However, opioid use has been associated with adverse effects on maternal and fetal outcomes. Medications administered during epidural analgesia are systemically absorbed; therefore, we performed a retrospective cohort study to investigate whether Opioid-Free Labor Epidural Analgesia (OFLEA) is comparable to OLEA regarding maternal and infant outcomes at delivery. Of 1,423 patients initially identified, we excluded those with twin deliveries, duplicate records, or incomplete data. We then matched 1:1 on the mother's age, including 618 patients for final data analysis. Our OLFEA group included an epidural solution of 0.2% ropivacaine, while our OLEA group included an epidural solution of 0.1% ropivacaine + 250 mcg fentanyl. Wilcoxon rank-sum tests were performed to assess our primary outcome of time-weighted pain scores before and after epidural placement. Secondary outcomes included duration (minutes) of maternal hypotension, tachycardia, and bradycardia episodes during labor, and incidence of neonatal fever, C-section, and Apgar scores (1 and 5 mins after delivery). There was no significant difference between the OLEA and OFLEA groups in the time-weighted pain scores during labor before epidural placement. However, the time-weighted pain score was significantly lower in the OFLEA group (1.05 ± 1.52) compared to OLEA (1.43 ± 1.77, p = 0.006). Similarly, maximum pain scores after epidural were lower in OFLEA (3.32 ± 3.23) vs. OLEA (3.87 ± 3.33, p = 0.03). There were no significant differences in maternal hemodynamic events, Apgar scores, neonatal fever, or cesarean delivery rates. OFLEA is a safe and feasible alternative to OLEA. Avoidance of opioids may support safer maternal and neonatal care in obstetric anesthesia.
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. 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. 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. 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.
Surgery remains one of the most important treatments for breast cancer. In this context, the quality of postoperative recovery has become a key concern. Adequate control of acute pain is essential to optimize patient comfort and recovery. Pregabalin may contribute to this goal by preventing central sensitization and reducing perioperative anxiety. To evaluate the effect of perioperative pregabalin versus placebo on postoperative recovery quality in patients undergoing breast cancer surgery. In this randomized controlled trial, 92 patients received either pregabalin (150 mg orally, 1 hour before surgery) or a matching placebo, both prepared in identical capsules. The primary outcome was the QoR-15 score measured preoperatively, and at 24 and 48 hours postoperatively. The 24- and 48-hour assessments were conducted via telephone. The QoR-15 is a validated instrument that assesses the quality of recovery, with total scores ranging from 0 (very poor recovery) to 150 (excellent recovery). Secondary outcomes included opioid consumption, pain scores, incidence of nausea and vomiting, and lengths of stay in the Post-Anesthesia Care Unit (PACU) and hospital. An exploratory analysis of longitudinal changes in QoR-15 scores within each group was also performed. Analyses were performed per protocol. Eighty-four patients completed the study. There were no differences in overall QoR-15 score between the groups at any of the three assessment time points (preoperative, 24h, and 48h). In the exploratory longitudinal within-group analysis, better maintenance of recovery quality was observed in the pregabalin group compared with baseline, with medians (IQR) of 138 (122.3-145), 132.5 (125.8-135.3), and 134 (131.5-136) [p = 0.006 between 24h and 48h]. In the placebo group, the medians (IQR) were 140 (128-145.3), 129 (126-134.3), and 134 (126.8-136.3) [p = 0.002 between pre and 24h; p = 0.026 between pre and 48h]. Although exploratory analysis showed a trend toward improvement within the pregabalin group, there was no significant difference in QoR-15 scores between groups.
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. 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). 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). 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.
Severe odontogenic infections requiring surgical drainage pose significant airway management challenges. This study aimed to compare perioperative characteristics and clinical outcomes between patients managed with conventional laryngoscopy versus awake fiberoptic intubation, to identify factors associated with the selection of airway management technique, and to determine predictors of hospital length of stay. This single-center retrospective study included 85 adult patients who underwent surgical drainage of severe odontogenic infections under general anesthesia between 2015 and 2024. The primary objective was to identify factors associated with awake fiberoptic intubation selection. Secondary objectives included comparison of perioperative outcomes and identification of predictors of hospital discharge. Multivariable logistic regression and Cox proportional hazards modeling were used. Of 85 patients, 60% were managed with AFOI. Multivariable analysis identified trismus (OR = 6.67, 95% CI 1.53, 39.53, p = 0.010) and higher BMI (OR = 1.15, 95% CI 1.03, 1.33, p = 0.013) as independent predictors of AFOI selection. AFOI patients experienced more complex postoperative courses, with intraoperative tracheostomy, ICU admission, and septic shock occurring exclusively in this group. Spontaneous ventilation postoperatively was associated with earlier discharge (HR = 2.14, 95% CI 1.23, 3.73, p = 0.007), while septic shock (HR = 0.26, 95% CI 0.07, 0.91, p = 0.036) and lower BMI (HR = 0.95, 95% CI 0.90, 1.00, p = 0.040) were associated with delayed discharge. AFOI was preferentially selected for anatomically complex odontogenic infections based on objective criteria, particularly trismus and elevated BMI. The ability to achieve spontaneous ventilation postoperatively serves as a key prognostic indicator, while septic shock is strongly associated with prolonged recovery. These findings support evidence-based airway management protocols and early identification of high-risk patients to optimize outcomes in this challenging population.
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. 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. 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). 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.
Meningitis remains the leading infectious cause of neurological disabilities globally, disproportionately affecting children younger than 5 years and populations in the African meningitis belt. Whereas previous global estimates focused on ten pathogen categories, this study presents the most comprehensive analysis to date, assessing the meningitis burden attributable to 17 causative pathogens based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 framework. GBD is a systematic, scientific effort aimed at quantifying the comparative magnitude of health loss caused by diseases, injuries, and risk factors across age groups, sexes, and geographical locations over time. We estimated meningitis mortality using the Cause of Death Ensemble model (CODEm) and morbidity using DisMod-MR 2.1, incorporating data from vital registration, verbal autopsy, surveillance, hospital data, and systematic reviews. Aetiology-specific estimates were generated with pathogen-linked case-fatality ratios and splined binomial regression models. Risk factor attribution was based on established risk-outcome pairs and population attributable fractions. In 2023, there were 259 000 (95% uncertainty interval 202 000-335 000) global deaths and 2·54 million (2·20-2·93) incident cases of meningitis. Children younger than 5 years accounted for more than a third of deaths (86 600 [53 300-149 000]). Streptococcus pneumoniae, Neisseria meningitidis, non-polio enteroviruses, and other viruses were the leading causes of death, while non-polio enteroviruses caused the most cases. The four WHO-defined preventable meningitis pathogens of interest (S pneumoniae, N meningitidis, Haemophilus influenzae, and Group B streptococcus) contributed to 98 700 deaths (77 000-127 000) and 594 000 cases (514 000-686 000). Low birthweight, short gestation, and household air pollution were the top risk factors for meningitis-related mortality. Although mortality and incidence have declined significantly since 1990, progress is insufficient to meet WHO 2030 targets. Despite marked progress in reducing bacterial meningitis via global vaccination campaigns, a substantial meningitis burden persists, attributable both to common pathogens such as S pneumoniae and N meningitidis and to emerging non-bacterial pathogens such as Candida spp and drug-resistant fungi. Achieving WHO goals will require sustained investment in surveillance, vaccination, maternal screening, and health-system strengthening, especially in high-burden settings. Gates Foundation, Wellcome Trust, and UK Department of Health and Social Care.
Coronary Artery Bypass Grafting (CABG) is the most widely used cardiac intervention and can be accomplished without an extracorporeal circulation off-pump. The benefits of antifibrinolytics in off-pump CABG have yet to be demonstrated. Randomized Controlled Trials (RCTs) and observational studies comparing the use of antifibrinolytic agents (tranexamic acid, aprotinin, and epsilon-aminocaproic) versus controls in patients undergoing off-pump CABG were searched in the PubMed, Embase, and Cochrane databases. Outcomes included thromboembolic events, in-hospital mortality, overall mortality, bleeding, Intensive Care Unit (ICU) length of stay, and blood product transfusions. Meta-analyses were conducted using the Inverse Variance method under a random-effects model, with p < 0.05 considered statistically significant. Of the 23,149 patients in 20 RCTs and seven observational studies, 51% received antifibrinolytic agents (tranexamic acid or aprotinin). Observational and randomized designs were analyzed separately in primary subgroup analyses. Significant reduction was found for overall mortality (RR = 0.72; [95% CI 0.54-0.95]) in the RCT subgroup. Red-blood-cell transfusion requirements were reduced (RR = 0.65; [95% CI 0.53, 0.78]) as well as Platelets (RR = 0.59; [95% CI 0.41, 0.84]) and fresh-frozen-plasma (RR = 0.39; [95% CI 0.36, 0.42]) transfusion requirement. The RCT subgroup showed a reduction in thromboembolic events (RR = 0.55; [95% CI 0.39, 0.79]). In off-pump CABG, antifibrinolytics reduced the need for blood transfusion while reducing thromboembolic events and overall mortality in RCT subgroups, while pooled analyses combining RCTs and observational studies did not demonstrate significant reductions. PROSPERO LINK: https://www.crd.york.ac.uk/PROSPERO/view/CRD42024545640.
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. 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. 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. 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.
Preoperative carbohydrate-containing clear liquids are recommended to reduce discomfort associated with prolonged fasting, yet their implementation remains limited in many Brazilian hospitals. This study evaluated the sensory acceptance and clinical effects of an instant coffee-flavored carbohydrate beverage administered during the preoperative period. A randomized controlled trial was conducted between March 2022 and December 2024 at a tertiary hospital in Brazil. Adult patients scheduled for elective surgery under general anesthesia were allocated to a test group (200 mL carbohydrate beverage up to two hours before anesthesia induction) or a control group (conventional fasting of approximately 8 hours). Clinical assessments were performed approximately two hours before anesthesia induction. The primary outcome was satiety, assessed using a 0‒10 Numerical Rating Scale (NRS). Secondary outcomes included thirst and anxiety. In the test group, palatability, satisfaction, and perceived anxiety control were also evaluated. The beverage demonstrated good sensory acceptance and was well tolerated. Compared with conventional fasting, participants who received the beverage reported significantly higher satiety scores and lower levels of thirst and anxiety. Among participants with higher baseline anxiety (≥ 7), exploratory descriptive findings suggested favorable perceived anxiety control following beverage intake. No adverse events were observed during the study period; however, the study was not powered to detect rare adverse events. Administration of the beverage up to two hours before anesthesia was associated with reduced preoperative discomfort and high patient acceptance. Larger studies are needed to further evaluate clinical outcomes and safety.
Remimazolam, a short-acting benzodiazepine, has emerged as a potential safer alternative for sedation in Flexible Bronchoscopy (FB). This meta-analysis compares its efficacy and safety with Propofol, Dexmedetomidine, and Midazolam in adult patients undergoing FB. PubMed, Embase, and Cochrane databases were searched on July 17, 2025, for trials comparing Remimazolam with other sedatives. Primary outcomes included hypotension, bradycardia, and intraprocedural opioid consumption; secondary outcomes were hypoxia, respiratory depression, patient satisfaction, induction time, and recovery time. Pooled Risk Ratios (RR), Mean Differences (MD), and Standardized Mean Differences (SMD) were calculated using a random-effects model in R (4.4.0). Risk of bias was assessed using the RoB2 tool, and subgroup analyses were conducted for each comparator. Eleven trials (1,884 patients) were included. Remimazolam reduced respiratory depression (RR = 0.44 [95% CI 0.29; 0.67]; p = 0.0002; I² = 0%), hypoxia incidence (RR = 0.60 [95% CI 0.39; 0.93]; p = 0.0227; I² = 64.7%), bradycardia (RR = 0.39 [95% CI 0.20; 0.77]; p = 0.0069; I² = 52.3%), and hypotension (RR = 0.61 [95% CI 0.40; 0.95]; p = 0.0289; I² = 74.0%) compared to all sedatives. Compared to Propofol, Remimazolam reduced the incidence of hypotension (RR = 0.42 [95% CI 0.31; 0.58]; p < 0.0001; I² = 0%), respiratory depression (RR = 0.41 [95% CI 0.25; 0.68]; p = 0.0005; I² = 12.3%), but increased induction time (MD = 0.61 min [95% CI 0.23; 0.99]; p = 0.002; I² = 90.9%). Compared to Dexmedetomidine, it improved satisfaction (SMD = 0.23 [95% CI 0.07; 0.39]; p = 0.004; I² = 0%) and reduced recovery time (MD = -1.79 min [95% CI -2.66; -0.92]; p < 0.001; I² = 90.7%), hypoxia incidence (RR = 0.49 [95% CI 0.28; 0.88]; p = 0.0162; I² = 60.3%), and induction time (MD = -2.21 min [95% CI -2.41; -2.00]; p < 0.001; I² = 0%). Compared to Midazolam, Remimazolam increased sedation success (RR = 2.03 [95% CI 1.40; 2.95]; p = 0.0002; I² = 50%), shortened induction time (MD = -0.69 min [95% CI -1.37; -0.01]; p = 0.047; I² = 81.5%), and recovery time (MD = -4.49 min [95% CI -7.06; -1.92]; p < 0.001; I² = 40.9%). Remimazolam reduced respiratory depression overall and demonstrated improved safety, faster recovery, and greater efficacy compared to Propofol, Dexmedetomidine, and Midazolam, respectively, supporting its potential as an effective alternative for sedation in FB. Nonetheless, substantial heterogeneity in certain outcomes and the relatively small sample size in some comparisons limit the generalizability of our findings. PROSPERO (CRD 42024568148).
Neuromuscular blockers such as succinylcholine are widely used for airway management in critically ill patients; but their use may be contraindicated due to adverse effects. In rapid sequence intubation, the onset time of the neuromuscular blocker is critical and should be as short as possible. This study investigates whether lidocaine and magnesium sulfate could reduce the onset time of rocuronium bromide in an experimental model. Eighteen animals were randomly assigned to three groups and treated with lidocaine, magnesium sulfate, or saline before receiving rocuronium bromide (3 mg.kg-1). After 10 minutes of neuromuscular blockade, reversal was performed with sugammadex (9 mg.kg-1). Onset and reversal times were measured by acceleromyography. Doses were standardized in a pilot study with four animals. Data were tested for normality using the Shapiro-Wilk and Anderson-Darling tests. Onset times are tested with a one-way ANOVA, followed by Fisher's (LSD) post hoc test, and mean arterial pressure and heart rate with a two-way ANOVA, followed by Tukey's post hoc test. Statistical significance was set at p ≤ 0.05. The results showed that lidocaine and magnesium sulfate significantly reduced the onset time of rocuronium bromide compared to the saline solution (p < 0.05) and did not affect the onset time of reversal with sugammadex (p > 0.05). Both adjuvants caused hypotension, with a more significant effect observed with magnesium sulfate; however, blood pressure returned to baseline values. In conclusion, lidocaine and magnesium sulfate facilitate airway access by reducing the onset time of rocuronium bromide. Animal Ethics Committee approved 1749/2022.
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Outpatient preanesthetic consultation improves patient assessment and anesthetic planning, enhancing safety and reducing complications. Conducted in advance, it allows systematic, individualized planning. Uncontrolled hypertension, common in 60% of people over 60, is a major cause of surgery cancellation and increases cardiovascular risk. This study evaluates its impact on preventing perioperative complications and optimizing clinical and surgical outcomes in urological patients. This retrospective observational study analyzed 700 patients (≥ 18 years) who attended outpatient preanesthetic consultation before urological surgery. Clinical conditions, systemic blood pressure, heart rate was analyzed during outpatient, preoperative, and intraoperative periods. Preoperative and intraoperative complications were recorded to evaluate consultation impact. Among 700 patients (89.6% male, mean age 64.2), ASA II was most common classification. Hypertension was identified in 53.7% of patients during outpatient evaluation. All hypertensive patients received antihypertensive treatment until surgery, with blood pressure maintained within normal limits. Preoperative findings in the operating room included hypertension (2.0%), anemia (0.57%), atrial fibrillation (0.14%), and asthma (0.14%). Intraoperative events included hypertension (2.28%), hypotension (8.14%), bradycardia (1.14%), and inadequate neuraxial block (2.85%). One surgery was canceled due to hypertension. Blood pressure significantly decreased preoperatively and intraoperatively compared to outpatient values (p < 0.0001). Heart rate also decreased significantly intraoperatively. This single-center study has limitations, including absence of comparison groups assessed by other specialties or only day of surgery. Reductions in systolic and diastolic blood pressure were documented upon operating room entry among patients evaluated in outpatient preanesthetic consultation, with a very low surgery cancellation rate.
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). 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. 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. 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.
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. 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. 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. 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. Externation (Discharge) of ICU, NCT06584890, registered 03 September 2024, prospectively registered, https://register. gov/prs/beta/studies/S000EVXZ00000029/recordSummary.