Nothing new today — the ESAIC/ESRA antithrombotic guideline and STS on oligometastatic lung cancer

No new guidelines from tracked societies today. Fourteen journals swept for 4–6 September, zero hits and zero query failures — a confirmed negative, not a silent one. A Sunday, as expected.

Two more off the landmark backlog, both squarely primary scope and both with deposited abstracts.

Regional anaesthesia in patients on antithrombotic drugs — joint ESAIC/ESRA guidelines

Society · Published: European Society of Anaesthesiology and Intensive Care with the European Society of Regional Anaesthesia. European Journal of Anaesthesiology, February 2022 — ~4.5 years old, endorsed by the Scandinavian society in May 2022, and still the reference document Kietaibl, Ferrandis, Godier, Llau, Lobo, Macfarlane, Vandermeulen, Volk, von Heymann, Afshari et al.

Systematic search across seven drug comparators and ten types of clinical intervention, outcome peripheral and neuraxial haematoma, GRADE plus a Delphi process.

• Certainty of evidence was GRADE C throughout — clinical studies limited in number and quality
• 40 clinical practice statements; strong consensus (>90% agreement) on 57.5%, consensus (75–90%) on the remaining 42.5%

The substance:

• Specific time intervals apply before and after neuraxial procedures, and before and after peripheral nerve blocks with higher bleeding risk — deep and noncompressible
• Intervals vary by drug type and dose, renal function, and whether the puncture was traumatic
• Drug measurements may guide certain intervals; specific reversal for vitamin K antagonists and dabigatran may modify them
• Ultrasound guidance, drug combinations and bleeding risk scores do NOT modify the time intervals
• For low-bleeding-risk blocks — superficial and compressible — the intervals do not apply

Interpretation. Two lines here are worth having exactly right, because both are commonly got wrong in the opposite directions.

Ultrasound guidance does not shorten the intervals. The intuition that seeing the needle makes an anticoagulated block safe is explicitly rejected, and it is a temptation that grows as ultrasound skill grows. Nor do bleeding risk scores buy you time.

The deep/noncompressible versus superficial/compressible distinction is the whole practical structure. The intervals do not apply to low-risk blocks — which means a great deal of everyday regional practice is unaffected, and treating the neuraxial intervals as universal is an over-restriction that costs patients analgesia for no safety gain.

Worth noting the honesty of the evidence base: GRADE C throughout, and 42.5% of statements reaching only 75–90% agreement. This is a document built on consensus because the trials do not exist, which is worth remembering when it is quoted as though it were settled fact. It also sits directly against the BJA paravertebral-versus-ESP trial and the 2026 ASA regional analgesia guideline already in this archive — the field’s enthusiasm for deep fascial plane blocks in cardiothoracic surgery runs into these intervals in exactly the anticoagulated population that cardiac surgery produces.

Read the guideline · PMID 34980845

STS guideline — surgical management of oligometastatic non-small cell lung cancer

Society · Published: Society of Thoracic Surgeons, Annals of Thoracic Surgery, 10 January 2025 — ~20 months old Antonoff, Mitchell, Kim, Salfity, Ripley, Donington et al.

A panel of thoracic surgical oncologists on the role of pulmonary resection as local consolidative therapy in oligometastatic NSCLC — a field the guideline describes as rapidly evolving, with practice varying widely institutionally and regionally and no evidence-based guidance previously available.

• Seven areas of controversy identified, with recommendations for each
• A number of issues were found to have a high level of evidence supporting surgical therapy in stage IV lung cancer
• But the nuances remain in equipoise: there is not ample evidence to support the extent of resection or the extent of nodal dissection

Conclusion: clear data support surgical resection of the primary tumour as local consolidative therapy in stage IV lung cancer, with recommendations aimed at multidisciplinary teams and at directing further research.

Interpretation. The headline is genuinely notable: surgery for stage IV lung cancer now has high-level evidence behind it in selected patients, which reverses decades of teaching that metastatic disease is a contraindication to resection. The oligometastatic concept has moved from hypothesis to guideline in about a decade.

The candid part is the second half. Evidence supports whether to operate; it does not yet support how much to take. Extent of resection and nodal dissection — the two decisions that most determine operative morbidity and the anaesthetic conduct — are explicitly left in equipoise. For a perioperative team, that means the case mix is expanding into patients previously deemed inoperable while the operative plan itself remains variable between surgeons and institutions.

It also connects to the single-port robotic thoracic series sent yesterday, which reported a median 29 nodes and all-R0 resections. Nodal harvest is precisely the parameter this guideline says is unsettled in the oligometastatic setting, so those numbers matter more than they might appear.

Read the guideline · PMID 39797869