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The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

AIRWAY MANAGEMENT

Obesity and increased risk of perioperative cardiac arrest (March 2024)

Obesity is a risk factor for difficulty with airway management and for rapid apneic oxygen desaturation during airway management. Both can result in hypoxic brain damage or death. In an analysis of causes of perioperative cardiac arrest reported to the Seventh National Audit Project (NAP7) in the United Kingdom, 35 percent of airway- and respiratory-related cardiac arrests occurred in patients with body mass index 35 to 50 kg/m 2 , while this cohort comprised only 12 percent of the survey population [ 1 ]. These findings reinforce the need to consider obesity when choosing general versus regional anesthesia and planning the airway management strategy. (See "Airway management for induction of general anesthesia", section on 'Obesity as a risk factor' .)

CARDIOVASCULAR AND THORACIC ANESTHESIA

Moderate hypothermia during aortic arch surgery with antegrade cerebral perfusion (March 2024)

Observational data have supported a shift from deep to moderate hypothermia during circulatory arrest for aortic arch surgery, particularly with adjunctive antegrade cerebral perfusion (ACP). A recent trial has now compared outcomes for 251 patients undergoing aortic arch surgery with ACP and randomly assigned to deep (≤20.0°C), low-moderate (20.1 to 24.0°C), or high-moderate (24.1 to 28.0°C) circulatory arrest temperature [ 2 ]. At one-month follow-up, the three groups had similar neurocognitive and neuroimaging outcomes and similar mortality, major morbidity, and quality of life. The volume of transfused blood products was higher in the deep group, but transfusion-related complications were not different. Based on this trial, moderate (20.1 to 28.0°C) rather than deep hypothermia is reasonable during aortic arch surgery when ACP is also used. Whether a low-moderate or high-moderate temperature is selected depends on the complexity of the arch intervention and the anticipated duration of hypothermia. (See "Overview of open surgical repair of the thoracic aorta", section on 'Hypothermic circulatory arrest' .)

OBSTETRIC ANESTHESIA

Labor epidural analgesia and risk of emergency delivery (December 2023)

It is well established that contemporary neuraxial labor analgesia does not increase the overall risk of cesarean or instrument-assisted vaginal delivery. However, a new retrospective database study of over 600,000 deliveries in the Netherlands reported that epidural labor analgesia was associated with an increased risk of emergency delivery (cesarean or instrument-assisted vaginal) compared with alternative analgesia (13 versus 7 percent) [ 3 ]. Because of potential confounders and lack of detail on epidural and obstetric management, we consider these data insufficient to avoid neuraxial analgesia or change the practice of early labor epidural placement to reduce the potential need for general anesthesia in patients at high risk for cesarean delivery. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Effects on the progress and outcome of labor' .)

PATIENT SAFETY

Use of a formal handoff tool during intraoperative transfer of anesthetic care (March 2024)

Intraoperative handoffs of care from one anesthesia provider to another have been associated with adverse outcomes, possibly due to inadequate communication of clinical information. A retrospective study noted that an intraoperative handoff (defined as transfer of care lasting more than 35 minutes) occurred in 40 percent of approximately 120,000 noncardiac surgical cases performed from 2016 to 2021 [ 4 ]. Adverse outcomes (defined as a composite of postoperative mortality or major morbidity) occurred more often when a handoff occurred (7.2 versus 6.2 percent with no handoff). After implementation of a structured electronic handoff tool in 2019, a correlation over time was noted between increased handoff tool usage and decreased likelihood of the composite adverse outcome. We use a formal handoff protocol during all phases of perioperative care. (See "Handoffs of surgical patients", section on 'Use of a formal handoff procedure' .)

PEDIATRIC ANESTHESIA

New guidelines for airway management in infants (January 2024)

Very young children are at higher risk of complications of airway management than children in older age groups; however, guidelines for infants have been lacking. In 2024, the European Society of Anesthesiology and Intensive Care and the British Journal of Anesthesia published joint guidelines for airway management in neonates and infants [ 5 ]. A summary of their recommendations appears in the following table ( table 1 ). (See "Airway management for pediatric anesthesia", section on 'Pediatric airway management guidelines' .)

Videolaryngoscopy for endotracheal intubation in critically ill children (January 2024)

Use of videolaryngoscopy (VL) in children provides a shared view during emergency endotracheal intubation (ETI) that permits an experienced physician observer to give assistance to the proceduralist. In a multicenter quality study of VL during ETI in pediatric intensive care units with standardized coaching by an attending, over 3500 ETIs were performed with VL, and use of VL increased from 30 percent to 89 percent of ETIs over four years [ 6 ]. Compared with direct laryngoscopy, VL was associated with lower adverse events (9 versus 15 percent). The majority of proceduralists were residents or fellows. These findings and prior studies confirm the safety of VL during emergency ETI in children and demonstrate the value of standardized coaching during the procedure for less experienced clinicians. (See "Technique of emergency endotracheal intubation in children", section on 'Video versus direct laryngoscopy' .)

PREOPERATIVE AND POSTOPERATIVE MANAGEMENT

Association of preoperative anemia with adverse outcomes after cardiac surgery (March 2024)

Studies continue to show a high rate of preoperative anemia in patients undergoing cardiac surgery and an association with adverse surgical outcomes. In a retrospective study of >4000 patients undergoing coronary artery bypass grafting surgery, 30 percent had preoperative anemia, which was associated with dose-dependent increases in postoperative acute kidney injury (AKI) and longer hospital stay [ 7 ]. In a 2024 meta-analysis with nearly 160,000 patients who underwent cardiac surgery, 28 percent had preoperative anemia, which was associated with increased mortality, AKI, other morbidities, and longer hospital stay [ 8 ]. When feasible, we postpone major surgery in patients with anemia to diagnose the cause and provide treatment. (See "Perioperative blood management: Strategies to minimize transfusions", section on 'Treatment of anemia' .)

Postoperative noninvasive ventilation or high-flow nasal oxygen for patients with obesity (November 2023)

The optimal postoperative ventilatory strategy for patients with severe obesity has been unclear. In a 2023 network meta-analysis of randomized trials that compared various postoperative noninvasive ventilatory strategies in these patients, high-flow nasal oxygen (HFNO) or bilevel positive airway pressure (BiPAP) reduced atelectasis; HFNO, BiPAP, or continuous positive airway pressure (CPAP) reduced postoperative pneumonia; and HFNO reduced length of stay compared with conventional oxygen therapy [ 9 ]. For patients with obesity who are hypoxic in the post-anesthesia care unit despite oxygen supplementation and incentive spirometry, we suggest a trial of HFNO, BiPAP, or CPAP prior to considering intubation. (See "Anesthesia for the patient with obesity", section on 'Post-anesthesia care unit management' .)

SURGICAL CRITICAL CARE

Tranexamic acid for burn wound excision (November 2023)

Randomized trials have established that tranexamic acid (TXA) reduces blood loss and transfusion requirements in various surgical settings, but data in burn surgery are limited. In a meta-analysis of observational studies evaluating intravenous and topical TXA in burn surgery, use of TXA was associated with reductions in blood loss, use of intraoperative transfusion, and number of units transfused but no change in venous thromboembolism or mortality rates [ 10 ]. Based on this review and data from other surgical settings, we routinely administer intravenous TXA for burn wound excisions over 20 percent of total body surface area. (See "Overview of the management of the severely burned patient", section on 'Coagulopathy' .)

OTHER ANESTHESIA

Updated guideline on postoperative delirium in adults (February 2024)

The European Society of Anaesthesiology and Intensive Care Medicine has published an updated guideline on postoperative delirium (POD) [ 11 ]. Recommendations include preoperatively screening older adults for risk factors for POD and multicomponent nonpharmacological interventions for all patients with risk factors. In addition, review of recent evidence showed that perioperative use of dexmedetomidine was associated with a lower incidence of POD, particularly when administered postoperatively in the intensive care unit. We agree with the recommendations and often use dexmedetomidine in the perioperative period to reduce the incidence of POD in high-risk patients. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with lower risk' .)

Supplemental neuraxial or regional analgesia and postoperative neurocognitive disorders (January 2024)

Supplementing general anesthesia with neuraxial or regional analgesic techniques reduced postoperative neurocognitive disorders (PND) and/or delirium in some studies, but results have been inconsistent. Differences in techniques and timing of analgesic administration, and confounding patient variables may explain the inconsistencies. In a meta-analysis of randomized trials of patients undergoing major noncardiac surgery under general or neuraxial anesthesia, supplemental postoperative neuraxial or regional analgesia (eg, epidural or peripheral or fascial plane block) reduced PND (both delirium and delayed neurocognitive recovery) in the first postoperative month compared with no supplemental analgesia [ 12 ]. Although supplemental analgesia may reduce PND, selection of anesthetic techniques is based primarily on other considerations. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Choice of anesthetic technique' .)

Thyroid hormone administration in deceased organ donors (December 2023)

Thyroid hormone administration has been a longstanding component of some organ procurement protocols due to concern that acute hypothyroidism might contribute to hemodynamic instability and left ventricular dysfunction, reducing heart and other organ procurement; however, evidence for the practice has been inconsistent. In a recent trial of 838 hemodynamically unstable, brain-dead donors assigned to receive a levothyroxine infusion or saline placebo, there was little to no difference in number of hearts transplanted or 30-day cardiac graft survival [ 13 ]. Recovery of other organs was similarly unaffected. More cases of severe hypertension or tachycardia occurred in the levothyroxine group than in the saline group. Based on these data, we suggest avoiding thyroid hormone administration in deceased organ donors. (See "Management of the deceased organ donor", section on 'Thyroid hormone' .)

Aerosol generation during noninvasive respiratory support modalities (October 2023)

Studies have reported conflicting data as to whether high levels of aerosols are generated when noninvasive ventilation (NIV) or high-flow nasal oxygen (HFNO) is used. In a 2023 systematic review including 12 studies in patients with respiratory infections and 15 studies in healthy volunteers, use of NIV or HFNO was not associated with increased generation of pathogen-laden aerosols compared with controls with unsupported normal or labored breathing, low-flow nasal oxygen, or oxygen or nonrebreather mask [ 14 ]. Inconsistency among studies may reflect differences in sampling and detection methodologies and operating room ventilation. Notably, the National Health Service in the United Kingdom has removed mask ventilation, intubation, and extubation from its list of aerosol-generating procedures. (See "Overview of infection control during anesthetic care", section on 'Considerations during aerosol-generating procedures' .)

Effectiveness of intraoperative blood salvage for reducing need for allogenic transfusion (October 2023)

Intraoperative blood salvage is a blood conservation technique in which autologous blood is aspirated, concentrated, washed, and reinfused. A 2023 meta-analysis of randomized trials involving >14,000 patients found that it reduced the need for allogeneic red blood cell transfusions in cardiovascular surgery with or without cardiopulmonary bypass and in major orthopedic hip, knee, or spine surgery [ 15 ]. Benefits were uncertain in vascular, cancer, and obstetric surgery. We recommend intraoperative blood salvage in surgical procedures with blood loss >750 mL, particularly if transfusion of allogeneic blood is likely. (See "Surgical blood conservation: Intraoperative blood salvage", section on 'Benefits' .)

• Cook TM, Oglesby F, Kane AD, et al. Airway and respiratory complications during anaesthesia and associated with peri-operative cardiac arrest as reported to the 7th National Audit Project of the Royal College of Anaesthetists. Anaesthesia 2024; 79:368.
• Hughes GC, Chen EP, Browndyke JN, et al. Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest Trial (GOT ICE): A Randomized Clinical Trial Comparing Outcomes After Aortic Arch Surgery. Circulation 2024; 149:658.
• Damhuis SE, Groen H, Thilaganathan B, et al. Effect of intrapartum epidural analgesia on rate of emergency delivery for presumed fetal compromise: nationwide registry-based cohort study. Ultrasound Obstet Gynecol 2023; 62:668.
• Saha AK, Segal S. A Quality Improvement Initiative to Reduce Adverse Effects of Transitions of Anesthesia Care on Postoperative Outcomes: A Retrospective Cohort Study. Anesthesiology 2024; 140:387.
• Disma N, Asai T, Cools E, et al. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Br J Anaesth 2024; 132:124.
• Giuliano J Jr, Krishna A, Napolitano N, et al. Implementation of Video Laryngoscope-Assisted Coaching Reduces Adverse Tracheal Intubation-Associated Events in the PICU. Crit Care Med 2023; 51:936.
• Warner MA, Hanson AC, Schulte PJ, et al. Preoperative Anemia and Postoperative Outcomes in Cardiac Surgery: A Mediation Analysis Evaluating Intraoperative Transfusion Exposures. Anesth Analg 2024; 138:728.
• Lau MPXL, Low CJW, Ling RR, et al. Preoperative anemia and anemia treatment in cardiac surgery: a systematic review and meta-analysis. Can J Anaesth 2024; 71:127.
• Li R, Liu L, Wei K, et al. Effect of noninvasive respiratory support after extubation on postoperative pulmonary complications in obese patients: A systematic review and network meta-analysis. J Clin Anesth 2023; 91:111280.
• Fijany AJ, Givechian KB, Zago I, et al. Tranexamic acid in burn surgery: A systematic review and meta-analysis. Burns 2023; 49:1249.
• Aldecoa C, Bettelli G, Bilotta F, et al. Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients. Eur J Anaesthesiol 2024; 41:81.
• Singh NP, Makkar JK, Borle A, Singh PM. Role of supplemental regional blocks on postoperative neurocognitive dysfunction after major non-cardiac surgeries: a systematic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med 2024; 49:49.
• Dhar R, Marklin GF, Klinkenberg WD, et al. Intravenous Levothyroxine for Unstable Brain-Dead Heart Donors. N Engl J Med 2023; 389:2029.
• Zhang MX, Lilien TA, van Etten-Jamaludin FS, et al. Generation of Aerosols by Noninvasive Respiratory Support Modalities: A Systematic Review and Meta-Analysis. JAMA Netw Open 2023; 6:e2337258.
• Lloyd TD, Geneen LJ, Bernhardt K, et al. Cell salvage for minimising perioperative allogeneic blood transfusion in adults undergoing elective surgery. Cochrane Database Syst Rev 2023; 9:CD001888.

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Lidocaine effects on neutrophil extracellular trapping and angiogenesis biomarkers in postoperative breast cancer patients with different anesthesia methods: a prospective, randomized trial

Anesthesia techniques and drug selection may influence tumor recurrence and metastasis. Neutrophil extracellular trapping (NETosis), an immunological process, has been linked to an increased susceptibility to ...

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Predictive value of S100B and brain derived neurotrophic factor for radiofrequency treatment of lumbar disc prolapse

This work aimed to analyze serum S100B levels and brain-derived neurotrophic factor (BDNF) in patients with lumbar disc prolapse to test their predictive values concerning the therapeutic efficacy of pulsed ra...

Correction: Evaluation the quality of bag-mask ventilation by E/C, T/E and hook technique (a new proposed technique)

The original article was published in BMC Anesthesiology 2023 23 :384

Continuous serratus posterior superior intercostal plane block for postoperative analgesia management in the patient who underwent right atrial mass excision: a case report

Serratus posterior intercostal plane block (SPSIPB) is a novel periparavertebral block. It provides anterolateral posterior chest wall analgesia. It is an interfascial plane block, performed under ultrasound g...

Impact of sarcopenia in elderly patients undergoing elective total hip arthroplasty on postoperative outcomes: a propensity score-matched study

Frailty poses a crucial risk for postoperative complications in the elderly, with sarcopenia being a key component. The impact of sarcopenia on postoperative outcomes after total hip arthroplasty (THA) is stil...

Determinants of difficult laryngoscopy based on upper airway indicators: a prospective observational study

The main cause of anesthesia-related deaths is the failure to manage difficult airways. Difficult laryngoscopic exposure is a major cause of unsuccessful management of difficult airways. Inadequate preoperativ...

Erector spinae plane block did not improve postoperative pain-related outcomes and recovery after video-assisted thoracoscopic surgery : a randomised controlled double-blinded multi-center trial

There is a sizable niche for a minimally invasive analgesic technique that could facilitate ambulatory video-assisted thoracoscopic surgery (VATS). Our study aimed to determine the analgesic potential of a sin...

Optimizing nicardipine dosage for effective control of pituitrin-induced hypertension in laparoscopic myomectomy undergoing total intravenous anesthesia

This study aimed to determine the median effective dose (ED50) and 95% effective dose (ED95) of nicardipine for treating pituitrin-induced hypertension during laparoscopic myomectomy, providing guidance for th...

Perioperative serum syndecan-1 concentrations in patients who underwent cardiovascular surgery with cardiopulmonary bypass and its association with the occurrence of postoperative acute kidney injury: a retrospective observational study

Various factors can cause vascular endothelial damage during cardiovascular surgery (CVS) with cardiopulmonary bypass (CPB), which has been suggested to be associated with postoperative complications. However,...

Regional analgesia using ultrasound-guided intermediate cervical plexus block versus cervical erector spinae block for anterior cervical spine surgery: a randomized trial

Regional analgesia techniques are crucial for pain management after cervical spine surgeries. Anesthesiologists strive to select the most effective and least hazardous regional analgesia technique for the cerv...

Comparison of bicarbonate Ringer’s solution with lactated Ringer’s solution among postoperative outcomes in patients with laparoscopic right hemihepatectomy: a single-centre randomised controlled trial

The study was aimed to investigate the positive impact of bicarbonate Ringer’s solution on postoperative outcomes in patients who underwent laparoscopic right hemihepatectomy. Patients in the two groups were i...

Effect of converting from propofol to remimazolam with flumazenil reversal on recovery from anesthesia in outpatients with mental disabilities: a randomized controlled trial

General anesthesia is often necessary for dental treatment of outpatients with mental disabilities. Rapid recovery and effective management of postoperative nausea and vomiting (PONV) are critical for outpatie...

Double lumen endobronchial tube intubation: lessons learned from anatomy

Double lumen endobronchial tubes (DLTs) are frequently used to employ single lung ventilation strategies during thoracic surgical procedures. Placement of these tubes can be challenging even for experienced cl...

50% efficacy dose of intravenous lidocaine in supressing sufentanil-induced cough in children: a randomised controlled trial

Opioids such as sufentanil are used as anaesthetics due to their rapid action and superior analgesic effect. However, sufentanil induces a huge cough in paediatric patients. In contrast, intravenous (IV) lidoc...

Profound hypoxemia and hypotension during posterior spinal fusion in a spinal muscular atrophy child with severe scoliosis: a case report

Anesthesia for spinal muscular atrophy (SMA) patients undergoing spinal deformity surgery is challenging. We report an unusual case of an SMA girl who developed severe intraoperative hypoxemia and hypotension ...

Application of propofol-remifentanil intravenous general anesthesia combined with regional block in pediatric ophthalmic surgery

The aim of this study is to observe the anesthetic effect and safety of intravenous anesthesia without muscle relaxant with propofol-remifentanil combined with regional block under laryngeal mask airway in ped...

Continuation of chronic antiplatelet therapy is not associated with increased need for transfusions: a cohort study in critically ill septic patients

The decision to maintain or halt antiplatelet medication in septic patients admitted to intensive care units presents a clinical dilemma. This is due to the necessity to balance the benefits of preventing thro...

The potentiating effect of intravenous dexamethasone upon preemptive pudendal block analgesia for hypospadias surgery in children managed with Snodgrass technique: a randomized controlled study

Evidence regarding the potentiating effects of intravenous dexamethasone on peripheral regional anesthesia in children is sparse. The objective of the current study was to investigate the potentiating effect o...

The efficacy and safety of perioperative glucocorticoid for total knee arthroplasty: a systematic review and meta-analysis

An increasing number of individuals undergo total knee arthroplasty (TKA), which can result in pain, limited motor function and adverse complications such as infection, nausea and vomiting. Glucocorticoids hav...

Anesthesia management for a child with the Koolen-de Vries syndrome: a case report

The Koolen-de Vries syndrome (KdVS) is a relatively new rare disease caused by micro-deletion of 17q21.31 which was first reported by Koolen in 2006. Typical phenotypes for KdVS include hypotonia, developmenta...

A novel combined approach to placement of a double lumen endobronchial tube using a video laryngoscope and fiberoptic bronchoscope: a retrospective chart review

The objective of this study was to evaluate a modern combined video laryngoscopy and flexible fiberoptic bronchoscope approach to placement of a double lumen endobronchial tube and further characterize potenti...

Retraction Note: Dose selection of central or peripheral administration of sufentanil affect opioid induced cough?: a prospective, randomized, controlled trial

This article has been retracted. Please see the Retraction Notice for more detail: https://doi.org/10.1186/s12871-024-02522-9.

One-year survival of aneurysmal subarachnoid hemorrhage after airplane transatlantic transfer – a monocenter retrospective study

Aneurysmal subarachnoid hemorrhage (aSAH) is preferentially treated by prompt endovascular coiling, which is not available in Guadeloupe. Subsequently, patients are transferred to Paris, France mainland, by co...

Association between serum calcium and prognosis in patients with acute ischemic stroke in ICU: analysis of the MIMIC-IV database

While serum Ca has proven to be a reliable predictor of mortality across various diseases, its connection with the clinical outcomes of ischemic stroke (IS) remains inconclusive. Our research aimed to explore ...

Effect of subclavian vein diameter combined with perioperative fluid therapy on preventing post-induction hypotension in patients with ASA status I or II

Perioperative hypotension is frequently observed following the initiation of general anesthesia administration, often associated with adverse outcomes. This study assessed the effect of subclavian vein (SCV) d...

Ultrasound-guided stellate ganglion block benefits the postoperative recovery of patients undergoing laparoscopic colorectal surgery: a single-center, double-blinded, randomized controlled clinical trial

With the increasing prevalence of colorectal cancer (CRC), optimizing perioperative management is of paramount importance. This study investigates the potential of stellate ganglion block (SGB), known for its ...

Machine learning approach for predicting post-intubation hemodynamic instability (PIHI) index values: towards enhanced perioperative anesthesia quality and safety

Adequate preoperative evaluation of the post-intubation hemodynamic instability (PIHI) is crucial for accurate risk assessment and efficient anesthesia management. However, the incorporation of this evaluation...

Timing of early water intake post-general anaesthesia: a systematic review and meta-analysis

Early water intake has gained widespread attention considering enhanced recovery after surgery (ERAS). In the present systematic evaluation and meta-analysis, we assessed the effects of early water intake on t...

Effect of epidural dexmedetomidine in single-dose combined with ropivacaine for cesarean section

Dexmedetomidine has arousal sedation and analgesic effects. We hypothesize that epidural dexmedetomidine in single-dose combined with ropivacaine improves the experience of parturient undergoing cesarean secti...

Laparoscopic assisted versus ultrasound guided transversus abdominis plane block in laparoscopic bariatric surgery: a randomized controlled trial

Transversus abdominis plane block (TAPB) guided by laparoscopy and ultrasound showed promise in enhancing the multimodal analgesic approach following several abdominal procedures. This study aimed to compare t...

Super-refractory status epilepticus, rhabdomyolysis, central hyperthermia and cardiomyopathy attributable to spinal anesthesia: a case report and review of literature

There are only six past reports of super-refractory status epilepticus induced by spinal anesthesia. None of those patients have died. Only < 15 mg of bupivacaine was administered to all six of them and to our...

Analysis of influencing factors and construction of prediction model for postoperative nausea and vomiting in patients undergoing laparoscopic sleeve gastrectomy: a single-center retrospective cohort study

With the increasing number of bariatric surgeries, the high incidence of postoperative nausea and vomiting (PONV) associated with this surgery has also gradually attracted attention. Among the common bariatric...

Skin mottling score assesses peripheral tissue hypoperfusion in critically ill patients following cardiac surgery

Skin mottling is a common manifestation of peripheral tissue hypoperfusion, and its severity can be described using the skin mottling score (SMS). This study aims to evaluate the value of the SMS in detecting ...

Incidence and factors associated with failed spinal anaesthesia among patients undergoing surgery: a multi- center prospective observational study

Failed spinal anaesthesia causes prolonging of operation time, insufficient analgesia for surgery and needs repeating spinal anaesthesia which in turn causes local anaesthesia toxicity, high spinal and total s...

Echocardiographic features of right ventricle in septic patients with elevated central venous pressure

Elevated central venous pressure (CVP) is deemed as a sign of right ventricular (RV) dysfunction. We aimed to characterize the echocardiographic features of RV in septic patients with elevated CVP, and quantif...

Sex differences in pain catastrophizing and its relation to the transition from acute pain to chronic pain

Differences exist between sexes in pain and pain-related outcomes, such as development of chronic pain. Previous studies suggested a higher risk for pain chronification in female patients. Furthermore, pain ca...

Sedation versus general anesthesia on all-cause mortality in patients undergoing percutaneous procedures: a systematic review and meta-analysis

The comparison between sedation and general anesthesia (GA) in terms of all-cause mortality remains a subject of ongoing debate. The primary objective of our study was to investigate the impact of GA and sedat...

Incidence of intraoperative hypotension and its factors among adult traumatic head injury patients in comprehensive specialized hospitals, Northwest Ethiopia: a multicenter observational study

Traumatic head injury (THI) poses a significant global public health burden, often contributing to mortality and disability. Intraoperative hypotension (IH) during emergency neurosurgery for THI can adversely ...

Impact of intraoperative hypothermia on the recovery period of anesthesia in elderly patients undergoing abdominal surgery

This study aimed to investigate the impact of intraoperative hypothermia on the recovery period of anesthesia in elderly patients undergoing abdominal surgery.

The effect of glycopyrrolate vs. atropine in combination with neostigmine on cardiovascular system for reversal of residual neuromuscular blockade in the elderly: a randomized controlled trial

Glycopyrrolate-neostigmine (G/N) for reversing neuromuscular blockade (NMB) causes fewer changes in heart rate (HR) than atropine-neostigmine (A/N). This advantage may be especially beneficial for elderly pati...

Thoracolumbar Interfascial Plane (TLIP) block verses other paraspinal fascial plane blocks and local infiltration for enhanced pain control after spine surgery: a systematic review

Spinal surgeries are accompanied by excessive pain due to extensive dissection and muscle retraction during the procedure. Thoracolumbar interfascial plane (TLIP) blocks for spinal surgeries are a recent addit...

Prevention of postoperative nausea and vomiting after orthognathic surgery: a scoping review

Postoperative nausea and vomiting (PONV) is one of the most common adverse events following orthognathic surgery. It’s a distressing feeling for patients and continues to be the cause of postoperative complica...

The value of local dexmedetomidine as an adjuvant to ultrasound-guided wide awake local anesthesia no tourniquet (WALANT) in flexor tendon repair surgeries: a randomized controlled trial

The Wide-Awake Local Anesthesia No Tourniquet (WALANT) technique allows intraoperative motor assessment of tendon repair integrity of the hand compared with general anesthesia or brachial plexus block. No stud...

Accelerated lymph flow from infusion of crystalloid fluid during general anesthesia

Kinetic analysis of crystalloid fluid yields a central distribution volume ( V c ) of the same size as the expected plasma volume (approximately 3 L) except during general anesthesia during which V c might be only ha...

Effects of remote ischemic preconditioning in hepatectomy: a systematic review and meta-analysis

Animal experiments have confirmed that remote ischemic preconditioning (RIPC) can reduce hepatic ischemia-reperfusion injuries (HIRIs), significantly improving early tissue perfusion and oxygenation of the res...

The effects of an IV fluid bolus on mitral annular velocity and the assessment of diastolic function: a prospective non-randomized study

Abnormal diastolic function is an independent predictor of adverse postoperative outcomes. Mitral annular tissue Doppler velocity (e’) is a key parameter for assessing diastolic function. The purpose of this s...

Effect of pretreatment with a small dose of esketamine on sufentanil-induced cough during anesthesia induction: a randomized controlled trial

Sufentanil-induced cough is common during the induction of anesthesia. The objective of this study was to determine whether pretreatment with a small dose of esketamine is effective in treating sufentanil-indu...

The effect of different endotracheal tube cuff pressure monitoring systems on postoperative sore throat in patients undergoing tracheal intubation: a randomized clinical trial

Postoperative sore throat (POST) is an unpleasant outcome that can occur as a result of tracheal intubation in adults. Increased pressure from the endotracheal tube (ETT) cuff often leads to local mucosal inju...

Preoperative routine measurement of NT-proBNP predicts postoperative morbidity after non-cardiac surgery with intermediate or high surgical risk: an observational study

Chronic heart failure (HF) is a common clinical condition associated with adverse outcomes in elderly patients undergoing non-cardiac surgery. This study aimed to estimate a clinically applicable NT-proBNP cut...

Combined sedation in pediatric magnetic resonance imaging: determination of median effective dose of intranasal dexmedetomidine combined with oral midazolam

The exact median effective dose (ED50) of intranasal dexmedetomidine combined with oral midazolam sedation for magnetic resonance imaging (MRI) examination in children remains unknow and the aim of this study ...

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• New Rules Require Explicit Consent for Students to Perform Sensitive Exams JAMA News April 26, 2024 Medical Education and Training Shared Decision Making and Communication Ethics Health Care Economics, Insurance, Payment Reproductive Health Full Text | pdf link PDF free

This randomized clinical trial assesses whether preoperative cognitive training reduces the incidence of delirium among patients in China undergoing coronary artery bypass grafting surgery.

This randomized clinical trial examines the effect of transcranial direct current stimulation (tDCS) on perioperative anxiety in patients undergoing colorectal cancer (CRC) resection in China.

This Viewpoint makes the case for academic health systems to lead the way on climate change action in the US, including planning to reduce greenhouse gas emissions, educating current and future clinicians, and communicating with their patients and communities.

This cohort study of adult patients with chronic pain assesses the association of physician empathy with patient outcomes, including patient-reported pain, function, and health-related quality of life.

This Viewpoint discusses the use of nerve blocks for pain during pelvic cancer treatment.

This cluster randomized clinical trial assesses the extent to which video laryngoscopy compared with direct laryngoscopy might facilitate intubation in patients undergoing surgical procedures during routine clinical practice.

This cohort study examines regional and institutional variation in overall opioid exposure and methadone treatment in high-risk infants at US children’s hospitals.

• Opioids in Hospitalized Infants—Managing Pain and Sedation While Avoiding Overuse JAMA Network Open Opinion March 12, 2024 Pediatrics Neonatology Pain Medicine Substance Use and Addiction Medicine Opioids Full Text | pdf link PDF open access

This systematic review investigates the association between choice of initial continuous intravenous anesthetic drug and treatment failure, adverse events, and mortality in patients with refractory status epilepticus.

This randomized clinical trial investigates the efficacy of perioperative adjunctive esketamine administration after cesarean deliveries in the prevention of postpartum depression.

This cross-sectional study investigates the association between glucagon-like peptide-1 receptor agonist use and prevalence of increased residual gastric content on gastrointestinal ultrasonography among fasted patients undergoing elective procedures under anesthesia.

This cohort study evaluates the association of the sequence of epinephrine administration and advanced airway placement with patient outcomes after out-of-hospital cardiac arrest in Japan.

This cohort study investigates the contributions of patients, clinicians, and hospitals to variation in intraoperative opioid administration for surgical procedures.

This cross-sectional study evaluates differences in general anesthesia use for cesarean delivery by race and ethnicity.

This Viewpoint discusses changes in the use of ketamine as a medical therapeutic and a recreational substance, the potential risks of use, and the need for increased research and surveillance.

This randomized clinical trial assesses whether esketamine as an adjuvant to propofol sedation leads to a reduced incidence of desaturation and hypotension during endoscopic procedures.

• Midazolam for Pregeneral Anesthesia Sedation—Aiming for Better Satisfaction in Elderly Patients JAMA Surgery Opinion December 20, 2023 Geriatrics Full Text | pdf link PDF
• Surgery, Anesthesia, and TBI Outcomes—Unraveling the Complex Interplay JAMA Surgery Opinion December 13, 2023 Traumatic Brain Injury Neurology Surgery Full Text | pdf link PDF

This cohort study surgery compares the addition of N-terminal pro–brain natriuretic peptide measures vs self-reported functional capacity to clinical scores estimating the risk of major adverse cardiovascular events among patients undergoing noncardiac surgery.

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Home > Books > Anesthesiology

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Published 08 February 2017

Doi 10.5772/63140

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Throughout the history of thousands of years of medicine, it felt a great need to anesthesia for surgical operations, and only in 1846, Morton's introduction of ether anesthesia began scientific anesthesiology. Today, as technological developments and knowledge have increased, the practices of anesthesiology are becoming increasingly sophisticated. In this book, current drugs and applications for ...

Throughout the history of thousands of years of medicine, it felt a great need to anesthesia for surgical operations, and only in 1846, Morton's introduction of ether anesthesia began scientific anesthesiology. Today, as technological developments and knowledge have increased, the practices of anesthesiology are becoming increasingly sophisticated. In this book, current drugs and applications for anesthesiology as well as new developments for the use of ultrasonography are presented.

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Guidelines and evidence-based recommendations in anaesthesia: where do we stand?

Lisa q. rong.

1 Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA

Katia Audisio

2 Department of Anesthesia, Intensive Care, and Emergency, Città della Salute e della Scienza Hospital, Turin, Italy

Sinead M. O'Shaughnessy

Clinical practice guidelines are increasingly important to guide clinical care. However, they can vary widely in quality, and many recommendations are based on low-level evidence. The COVID-19 pandemic highlighted the need for new flexible formats for rigorously developed guidelines. Future guideline development should be standardised, graded, registered, and updated to ensure that they are ‘living’ works in progress.

The number of clinical studies published has accelerated to the point where the amount of new medical information doubled every 72 days in 2020. 1 As a result, anaesthetists are increasingly reliant on summarised evidence in guidance documents, with the most important being clinical practice guidelines. Clinical practice guidelines are designed to improve and standardise patient care based on systematic reviews of evidence and expert consensus. Adherence to guidelines is increasing tied to reimbursement for clinical services and determination of quality of care. Unsurprisingly, practice guidelines are often widely distributed, downloaded, read, discussed, and cited. However, guidelines are imperfect and may lack integrity and quality, and contain low levels of evidence, recommendations discordant with evidence, and redundancy. Recent experience during the COVID-19 pandemic has also highlighted the need for guidelines to be adaptable yet rigorous. To improve this aspect, clinical practice guidelines should be graded and registered, and efforts should be made to combine resources when feasible. Clinicians should understand that guidelines are only as good as the evidence behind them and the people who make them.

Surprisingly, standardised criteria for clinical practice guideline development do not currently exist, and methodology and approaches for development can vary widely. Issues regarding their variable quality have been reported for years and include insufficient levels of evidence for formal recommendations, lack of inclusion of key stakeholders, lack of independence leading to bias, and poor applicability. 2 Although this should have improved with the call to action by the WHO, the Institute of Medicine, and Guidelines International Network, recent studies have shown that clinical practice guidelines in anaesthesia are frequently limited by conflicts of interest, are based on low levels of evidence, and often the level of evidence and strength of corresponding recommendations are discordant. Recent discussions have highlighted other forms of guidelines as necessary to address the speed and volume of new information resulting from global health emergencies, such as the COVID-19 pandemic, that require rapid dissemination of urgent guidance, often despite lack of robust evidence. Table 1 describes current advantages and disadvantages of various guideline formats. Although the focus of this editorial is on academic-led guidelines, the issues raised may also be highly relevant to government and regulator-led guidelines, which are often less evidenced based and lack rigorous development processes. In the UK, the National Institute for Health and Care Excellence (NICE), a government organisation that publishes online recommendations for clinical practice, has built considerable influence. Its guidance is not based on standard guideline development and is published online only. In addition, there is limited opportunity to challenge or report concerns on controversial statements. Outside of peer-reviewed/academic guidelines, it is important to note that many governments or society-published online guidelines exist with these additional limitations.

Table 1

Types of guidelines vs other guidance documents: definitions, advantages, and disadvantages. BJA, British Journal of Anaesthesia ; EJA, European Journal of Anaesthesiology ; NICE, National Institute for Health and Care Excellence.

What is wrong with guidelines?

Editorial independence.

Editorial independence during guideline synthesis is a key quality metric. 3 In the context of increasing conflicts of interest in medicine, many organisations, including the American College of Physicians, US Preventive Services Taskforce, and UK NICE, require anyone involved in clinical practice guideline development to disclose all financial/intellectual conflicts of interest in the preceding 3 yr according to their magnitude: high (active relationships with direct financial stakes in the guidelines), moderate (intellectual interest that may profit from the guidelines), and low (inactive conflicts of interests peripherally associated with the guidelines). 4 In 2011, the National Academy of Medicine report Clinical Practice Guidelines We Can Trust recommended that all financial conflicts be disclosed, that only a small number of authors have conflicts, and that chairpersons should not have any significant financial and academic conflicts of interest. 5 Given their high citation rates, participation of journal editors in guideline preparation creates another potential conflict of interest. Unfortunately, studies in the USA, Japan, and Australia have found that more than 70% of clinical practice guideline authors have financial conflicts with large discrepancies between publicly reported and self-disclosed conflicts of interest, and that chairpersons often have significant potential financial conflicts of interest. 6 Finally, it is worth mentioning that the author list is not always reflective of relative contributions or influence, and valuable input from reviewers often goes unrecognised. These hidden contributors may also need to display transparency and disclose appropriate conflicts of interest. In addition, industry influence cannot be fully excluded based on statements of individual conflicts of interest. The influence of pharmaceuticals on guidelines produced by the American Pain Society preceding the opioid crisis is a case in point.

Conflicts of interests

Conflicts of interests are often grey areas. These statements are self-reported declarations, which remain undefined by journals and the wider scientific community. Some societies have attempted to define ‘significant’ interests in a landscape where it is increasingly difficult to be free from all conflicts. For example, clinicians or researchers especially knowledgeable on a topic may be more likely to be approached by companies for paid consultation. Usually only ‘moderate or high’ levels of conflicts are considered significant and undesirable in guideline development. However, it remains at the discretion of guideline committees and societies to appropriately screen and avoid contributory conflicts of interest.

It is impossible to ensure that authors do not intend to benefit from guideline development that would create future conflicts of interest. The guideline in question remains unaffected, although this may prohibit involvement in future guideline involvement. One way to avoid this may be anonymous guidelines published solely in the name of a society. This may have unintended consequences, however, allowing authors to hide their prior conflicts of interest and cannot be recommended. We suggest instead that for the process to be transparent, a third-party regulator or administrator should examine all potential conflicts of interest and grade the level of conflict before finalising involvement in the guideline development group.

Strength of underlying evidence

Another key quality indicator of clinical practice guidelines is the strength of the underlying evidence. Assessing the level of evidence is more complex than might be expected. Commonly used tools for grading evidence include the Grading of Recommendations Assessment, Development and Evaluation (GRADE) 7 and the American College of Cardiology/American Heart Association (ACC/AHA) classification. 8 These instruments categorise evidence to Levels A, B, and C, with Levels A and B based on prospective studies and Level C representing more subjective sources, such as clinical experience, case reports, and expert opinion.

Assessment of levels of evidence

Systematic reviews, meta-analyses, and RCTs are considered the highest level of evidence but can be of variable methodological quality. The number of systematic reviews and meta-analyses has increased nearly five times in the last decade compared with clinical trials, which have grown only of the 55% during the same time period. 9 If best practices are not followed, many reviews may be biased and flawed, with questionable and often conflicting conclusions. Only 3% of meta-analyses produced represent high-quality work. In addition, meta-analyses of small trials are subject to publication bias and may overestimate treatment effects that are later disproved by large trials. If incorporated into guidelines, these reviews can affect the validity of recommendations. Inclusion of methodological experts as a gatekeeper is critical to maintaining guideline integrity.

Assessing RCT level of evidence can also be challenging. Using GRADE, studies can be upgraded or downgraded depending on the methodological rigour. 7 Small RCTs and single-centre RCTs may overestimate treatment effects because of unintentional investigator bias, and RCTs using composite outcomes to decrease sample size may have clinically less relevant outcomes ‘drive’ the composite outcome. Superiority trials with high crossover rates or protocol deviations may bias the trial towards the null hypothesis. In contrast, large observational studies, representing a more ‘real-world’ clinical setting and providing temporal trends in disease prevalence or interventions, may have significant value and may be upgraded in quality of evidence. Therefore, it takes experts in trial methodology, digging deep into the details of individual trials, to grade levels of evidence accurately.

Concordance of levels of evidence and strength of recommendations

A recent systematic review evaluating the levels of evidence of North American and European perioperative care clinical practice guidelines in the last 10 yr found that a minority (16%) of recommendations were supported by Level A evidence, whereas 51% were supported by Level C evidence. 10 More concerning, strong recommendations were often supported by a low level of evidence, a finding that did not improve during the study period. Tricoci and colleagues, 8 in an analysis of 53 ACC/AHA clinical practice guidelines published between 1984 and 2008 and including 7196 recommendations, reported that only 11% of recommendations were supported by the highest level of evidence, whereas nearly half were based only on expert opinions or case studies. An updated analysis of 26 ACC/AHA guidelines published between 2008 and 2018 reported that only 8.5% of the recommendations were supported by Level A evidence, 50% by Level B evidence, and 42% by Level C evidence. 11 Similarly, of 25 European Society of Cardiology guidelines, 14% of recommendations were supported by Level A, 31% by Level B, and 55% by Level C evidence.

Another problematic issue with clinical practice guidelines is the correct translation of existing evidence into recommendations. Different tools have been introduced to evaluate this aspect, with the Appraisal of Guidelines, Research and Evaluation (AGREE) and the GRADE instruments being the most commonly utilised. The GRADE system defines how evidence should be translated into treatment recommendations and provides an explicit evaluation of the comprehensive criteria for downgrading and upgrading quality of evidence ratings. 12 The validity of GRADE is supported by its endorsement by organisations, such as the WHO, the American College of Physicians, the American Thoracic Society, and the Cochrane Collaboration.

Tools used to assess guidelines

Grade instrument.

Although the GRADE system has not been universally accepted, it has frequently been used to assess the quality of clinical practice guidelines in anaesthesia. In an analysis of 681 recommendations from 15 clinical critical care guidelines published from 2011 to 2017, Sims and colleagues 13 found that amongst 215 Class 1 recommendations, 69 (32%) were discordantly paired with evidence other than Level A or B. Despite GRADE recommendations based on low-level evidence, 22 of 69 recommendations (32%) were based on expert consensus, and 47 (68%) of the guidelines were of low or very low quality. 13

AGREE instrument

The AGREE instrument, updated to AGREE II in 2011, is arguably the gold standard for clinical practice guideline development, reporting, and evaluation. 14 It has six domains, with Domain 3, Rigour of Development, regarded as the single most influential domain and most reflective of guideline quality. Several studies have used the AGREE II instrument to evaluate clinical practice guideline quality in anaesthesia. A study using AGREE II to access the quality of 96 guidelines in anaesthesia published between 2013 and 2018 found that 74% of them had low overall quality scores, and only 26% (25 out of 96) were of high quality. 15 A recent review used the AGREE II instrument to analyse the quality of clinical practice guidelines from all anaesthesia subspecialties from 2016 to 2020 and reported an increased overall quality of guidelines, mainly driven by Domain 3. The absolute score of Domain 3, however, remained low with only 13.7% of clinical practice guidelines deemed to be of high quality. Furthermore, eight subsections of Domain 3 demonstrated a variability in scores with quality assessment of the underlying evidence base having the lowest scores. 16 Future validated Domain 3 centric scoring systems may improve the accuracy of quality assessment and make AGREE II an even more reliable tool for clinical practice guideline evaluation.

A need for improved methodological approaches to anaesthesia guideline development is evident. Use of AGREE II together with the GRADE tool offers a potential solution. Mandating use of these tools together in guideline formation could lead to more-transparent high-quality documents. A recent review described high-quality guidelines as largely collaborative, with 78% having international involvement and 100% multi-institutional involvement. 16 International and institutional cooperation should be further emphasised in anaesthesia guideline development and also reduction in duplication of efforts. The ADAPTE, A Guideline Adaptation and Implementation Planning Resource (CAN-IMPLEMENT), and Grading of Recommendations Assessment, Development and Evaluation – Adaptation, Adoption, De Novo Development (GRADE-ADOLOPMENT) documents may play a role, having been designed for the purpose of efficiently developing and adapting clinical recommendations. 17 In addition, a standardised registry of clinical practice guidelines, similar to the International Prospective Register of Systematic Reviews (PROSPERO), should be implemented. Input from organisations, such as the WHO, Guidelines International Network, and Cochrane Collaboration, would be instrumental in supporting this process.

Role of journals

Clinical practice guidelines undergo a standard process of peer review before publication. However, journals do not comment on the quality of the guidelines, and publication in a specific journal does not always imply quality, particularly if the editorial team is involved in their development. Publication of an objective marker of guideline performance by the journal, such as AGREE II, along with the guideline itself should be considered to provide readers with a recognisable ‘quality mark’ reflecting the underlying integrity of the guideline. This does not imply that guidelines lacking this quality designation are inherently flawed, but that their recommendations should be viewed with some caution and with the understanding that there are grey areas in what is considered ‘best practice’. Similarly confusing for the reader are the various names and types of guidance documents ( Table 1 ). Journals should define the type of guidance document that is being presented because titles can be misleading.

Alternatives to guidelines

Focused clinical practice guidelines.

The current process of development and publication of clinical practice guidelines can take up to 2 yr. For COVID-19, the pandemic is just 2 yr old and hundreds of recommendations have been made. According to AGREE II, it is recommended that clinical practice guidelines are updated every 5 yr. For the COVID-19 pandemic, however, most guidelines have been based on low-level evidence and modified accordingly as higher-level evidence comes in, often reversing initial recommendations. In this context, updating clinical practice guidelines every 5 yr is inadequate. Conversely, for some recommendations, the evidence may not change significantly over time and updating them unnecessarily may waste resources. 18 In anaesthesia, the European Journal of Anaesthesiology (EJA) recently introduced a new format to streamline guideline updates, ‘the focused clinical practice guidelines’. 19

Focused clinical practice guidelines adhere to the same methodological structure as traditional guidelines, but they cover only a very specific topic and follow an expedited systematic review process. Therefore, they require less time from inception to publication, have a more efficient updating process, and have improved readability. 20 Whilst focused guidelines were initially considered of inferior quality, studies have found that there were no substantial differences in methodology, research strategy, and quality between traditional and focused clinical practice guidelines. 21 However, it should be noted that these may be much less comprehensive than traditional guidelines, and the cost of efficiency may be duplication and confusion: many focused guidelines covering similar material may complicate the message to the clinician. In addition, there may be value to approaching guidelines from the broad ‘forest’ viewpoint than from the ‘trees’ perspective. More and more specific guidelines on smaller topics published in subspecialty journals are contributing to this trend, and it remains unclear what the optimal balance between efficient and comprehensive is and the best size and scope of a clinical practice guideline.

Rapid statements

It should be noted that consensus statements exist widely to provide guidance in situations where there is clinical equipoise yet there is not enough evidence on a topic for systematic review and subsequent guideline development. The professional community should regard these as suggestions for practice rather than as binding recommendations. The EJA provided its take on consensus documents as ‘rapid statements’, in response to the COVID-19 health crisis emergency. These statements are less rigorous than clinical practice guidelines, but they are adaptable to the urgent needs arising from health crises, such as COVID-19, by aiming to disseminate the best available evidence as quickly as possible. 19 Rapid statements have been published prolifically during the COVID-19 pandemic, but many are of inferior quality and duplicative. 22 Strict standards should still be used in these statements. There is a growing body of literature detailing the application of GRADE and guidance for conducting rapid systematic reviews in the context of a pandemic. 23

Using high standards in the development of clinical practice guidelines may in fact be even more crucial in times of crisis, and rigour and speed should both be emphasised.

Living guidelines

The WHO recently introduced the concept of ‘living clinical practice guidelines’. 18 This approach combines continuous literature surveillance, rapid and constant updating of prioritised systematic reviews, and virtual consultations with expert panels to ensure that the latest evidence and updated recommendations can reach health workers worldwide as quickly as possible. For COVID-19, two clinical practice guidelines, one for treatment and one for prevention, have been developed adopting this strategy. 24 , 25 This concept has yet to be used in anaesthesia clinical practice guidelines, and a pertinent question remains regarding how and when updates should be made. Details on how living clinical practice guidelines should be incorporated in anaesthesia and what clinical questions would best suit this format depend on the rate of new information and interest in specific topics. The rate and degree of change should be set by (i) the rate of new evidence available and whether this evidence should change practice, and (ii) balancing the risks and benefits of frequent changes confusing readers. For medico-legal purposes and the evolving nature of practice recommendations, clear date stamps will be necessary to understand when a practice was recommended during previous versions of the guideline.

Conclusions

Evidence, recommendations, and clinical practice guidelines exist in an imperfect world. However, there are clear steps to improve guidelines ( Table 2 ). A more formal process must be performed to translate these suggestions into working recommendations; however, the hope is that these concepts will stimulate further debate. The integrity of guidelines must be taken seriously, and their development should be free from conflicts of interest. GRADE and AGREE II should be used to determine the quality of guidelines, assess evidence, and translate them accurately into recommendations. The ideal timing for updating guidelines is unknown. High-quality RCTs take years to complete, and clinical practice guidelines, rigorously performed, can also take several years to be finalised. Although it is surprising that so many recommendations are based on low-level evidence, this does not necessarily mean they are untrustworthy. Many clinical questions can be initially addressed with well-performed observational studies. Guidance for clinical practice is necessary despite the limitations of available evidence, but guidelines should be flexible to accommodate new information. When RCTs become available, their findings must be taken into account, perhaps even outside the timeline of traditional clinical practice guidelines. The COVID-19 pandemic has demonstrated the need for living guidelines that balance speed and rigour in the face of mass dissemination of information. These guidelines should still adhere to strict methodological standards that minimise duplication. Finally, the process of grading clinical practice guidelines should be standardised, and clinicians should be aware that all guidelines are ‘living’ works in progress that have limitations and may be updated as additional evidence accrues.

Table 2

Recommendations to improve clinical practice guideline development in anaesthesia. AGREE, Appraisal of Guidelines, Research and Evaluation; GRADE, Grading of Recommendations Assessment, Development and Evaluation.

Authors' contributions

Conception/design: LQR.

Drafting/revising of paper: all authors.

Final approval: all authors.

Accountability for all aspects of the work: all authors.

Declarations of interest

LQR is a member of the associate editorial board of the British Journal of Anaesthesia .

National Institutes of Health; National Heart, Lung, and Blood Institute (K23 HL153836-01A1) to LQR.

High-impact papers in the field of anesthesiology: a 10-year cross-sectional study

Affiliations.

• 1 Department of Anesthesiology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University and The Research Units of West China, Chinese Academy of Medical Sciences, Chengdu, China.
• 2 Department of Medical Administration, West China Hospital, Sichuan University, Chengdu, China.
• 3 Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China. [email protected].
• 4 Department of Periodical Press and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China. [email protected].
• 5 Department of Periodical Press and National Clinical Research Center for Geriatrics & Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China. [email protected].
• PMID: 36418743
• PMCID: PMC9684867
• DOI: 10.1007/s12630-022-02363-5

Abstract in English, French

Purpose: This study was performed to evaluate trends in and provide future direction for anesthesiology education, research, and clinical practice.

Methods: We collected high-impact papers, ranking in the top 10% in the field of anesthesiology and published from 2011 to 2020, by the InCites tool based on the Web of Science Core Collection. We analyzed the trends, locations, distribution of subject categories, research organizations, collaborative networks, and subject terms of these papers.

Results: A total of 4,685 high-impact papers were included for analysis. The number of high-impact papers increased from 462 in 2011 to 520 in 2020. The paper with the highest value of category normalized citation impact (115.95) was published in Anesthesia and Analgesia in 2018. High-impact papers were mainly distributed in the subject categories of "Anesthesiology," "Clinical Neurology," "Neurosciences," and "Medicine General Internal." They were primarily cited in "Anesthesiology," "Clinical Neurology," "Neurosciences," "Medicine General Internal," and "Surgery." Most of these high-impact papers came from the USA, UK, Canada, Germany, and Australia. The most productive institutions were the League of European Research Universities, Harvard University, University of Toronto, University of London, University of California System, and University Health Network Toronto. Research collaboration circles have been formed in the USA, UK, and Canada. Subject-term analysis indicated postoperative analgesia, chronic pain, and perioperative complications were high-interest topics, and COVID-19 became a new hot topic in 2020.

Conclusions: The current study provides a historical view of high-impact papers in anesthesiology in the past ten years. High-impact papers were mostly from the USA. Postoperative analgesia, chronic pain, and perioperative complications have been hot topics, and COVID-19 became a new topic in 2020. These findings provide references for education, research, and clinical practice in the field of anesthesiology.

RéSUMé: OBJECTIF: Cette étude a été réalisée pour évaluer les tendances et fournir une orientation future à l’enseignement, la recherche et la pratique clinique en anesthésiologie. MéTHODE: Nous avons colligé des articles à fort impact, classés dans le top 10 % dans le domaine de l’anesthésiologie et publiés de 2011 à 2020, par l’outil InCites basé sur la Web of Science Core Collection. Nous avons analysé les tendances, les emplacements, la répartition des catégories de sujets, les organismes de recherche, les réseaux de collaboration et les termes des sujets de ces articles. RéSULTATS: Au total, 4685 articles à fort impact ont été inclus pour analyse. Le nombre de manuscrits à fort impact est passé de 462 en 2011 à 520 en 2020. L’article ayant la valeur la plus élevée de l’impact normalisé des citations de catégorie (CNCI) (115,95) a été publié dans la revue Anesthesia and Analgesia en 2018. Les articles à fort impact ont été principalement distribués dans les catégories de thèmes « Anesthésiologie », « Neurologie clinique », « Neurosciences » et « Médecine générale interne ». Ils ont été principalement cités dans les catégories « Anesthésiologie », « Neurologie clinique », « Neurosciences », « Médecine générale interne » et « Chirurgie ». La plupart de ces articles à fort impact provenaient des États-Unis, du Royaume-Uni, du Canada, d’Allemagne et d’Australie. Les établissements les plus productifs étaient la League of European Research Universities, l’Université Harvard, l’Université de Toronto, l’Université de Londres, l’Université de Californie System et le University Health Network de Toronto. Des cercles de collaboration en recherche ont été formés aux États-Unis, au Royaume-Uni et au Canada. L’analyse des termes indiquait que l’analgésie postopératoire, la douleur chronique et les complications périopératoires étaient des sujets suscitant un fort intérêt, et la COVID-19 est devenue un nouveau sujet brûlant en 2020. CONCLUSION: La présente étude propose une vue historique des articles à fort impact en anesthésiologie au cours des dix dernières années. Les manuscrits à fort impact provenaient principalement des États-Unis. L’analgésie postopératoire, la douleur chronique et les complications périopératoires ont été des sujets d’actualité, et la COVID-19 est devenue un nouveau sujet en 2020. Ces résultats fournissent des références pour la formation, la recherche et la pratique clinique dans le domaine de l’anesthésiologie.

Keywords: InCites; anesthesiology; education; high-impact papers; research; visual analysis.

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Core Topics in Neuroanesthesia and Neurointensive Care.

University of Arkansas for Medical Sciences, Little Rock, Arkansas. [email protected]

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Indranil Chakraborty; Core Topics in Neuroanesthesia and Neurointensive Care.. Anesthesiology 2013; 118:232–233 doi: https://doi.org/10.1097/ALN.0b013e318278cb21

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I have a confession to make … Neuroanesthesiology is my first love! There you go, I said it!

So I really had my “neurotransmitters” in overdrive mode when I got the opportunity to review Core Topics in Neuroanesthesia and Neurointensive Care  , by Dr. Matta and his team. Unlike many other specialized fields of modern medicine, neuroanesthesia and neurointensive care have never enjoyed the luxury of having a plethora of quality texts, barring a few. So when the call came, my response was obvious!

The first thing that struck me when I held the book in my hand was its convenient size. That perfectly serves the declared purpose of this book, which is meant for conveniently accessible quick reference. I can easily see the reader tucking it in his/her carry bag to work for quick and definitive reference. I believe that is a big part of the demographic that the authors hope to target through this text.

Also interesting is an almost complete lack of vibrant and overzealous use of color in the design and text material of this book, which I must quickly add is not necessarily a bad thing. To be fair, for the more visually inclined there is a section of color plates in the middle of the book containing excellent-quality and relevant color photographs, imaging scans, line diagrams, among others. This design scheme, consisting mainly of black and white and different shades of gray, is not completely bereft of its admirers. In fact, as a reader, I personally get distracted by too much color in serious medical texts, which seems to be the norm these days. The simple design scheme of this book also keeps the production costs low, which is critical for books like these as they are not meant for mass consumption but are aimed at a niche readership.

Basic concepts in applied physiology and pharmacology, anesthesia, and critical care are increasingly being recognized as a part of the continuum of quality patient care and outcome. As is nicely described by the authors in the Preface of the book, “Practice in related subspecialty areas of anesthesia and critical care often relies on a common knowledge base and skill sets. Neuroanesthesia and neurocritical care represent areas of subspecialty practice where such interdependence is arguably most relevant.” To that goal, the text in the book is conveniently divided into four sections of applied clinical physiology and pharmacology, monitoring and imaging, neuroanesthesia, and neurointensive care, with a total of 36 chapters. This represents a perfect continuum of knowledge progression and keeps the reader’s thought process streamlined and the topics relevant and focused. The authors have also done a commendable job of including most of the relevant topics while restricting the text to fewer than 500 pages.

There is a certain novelty to simplicity and this book is a perfect example of that. The easy-to-read and -understand narrative of this book will strike a chord even in the most uninitiated. The authors, who are well-respected experts in this field, have been able to incorporate the latest information on fundamental physiologic concepts, advanced monitoring technologies, and clinical research and outcome analysis data into the text in such a way that the reader is neither intimidated nor distracted. A lot of emphasis is on the latest developments in neuromonitoring over the last decade, with extensive discussions on topics such as cerebral microdialysis, computer-aided multimodal monitoring and outcome analysis, near-infrared spectroscopy, and others. Along with the traditional topics in neuroanesthesia, there are also chapters dedicated to neuromuscular disorders, central nervous system infections and inflammation, and death and organ donation, as well as ethical and legal issues.

The chapters are well written and contain up-to-date information. The authors provide a list of suggested further readings at the end of each chapter. One could argue that there could be a scope for more specific references in the text. But, considering the stated objectives and the target readership of the book, that is just a minor point. In my humble opinion, in handling such complex and intimidating subjects as neuroanesthesia and neurointensive care, Dr. Matta and his team have been able to strike a delicate balance between a comfortable easy-to-grasp narrative and depth and richness of content.

And, Neuroanesthesia, you will always be my first love!

, University of Arkansas for Medical Sciences, Little Rock, Arkansas. [email protected]

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High-impact papers in the field of anesthesiology: a 10-year cross-sectional study

Manuscrits à fort impact dans le domaine de l’anesthésiologie : une étude transversale sur 10 ans

• Reports of Original Investigations
• Published: 23 November 2022
• Volume 70 , pages 183–190, ( 2023 )

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• Lingmin Chen PhD 1 ,
• Nian Li PhD 2 &
• Yonggang Zhang PhD 3 , 4 , 5  

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This study was performed to evaluate trends in and provide future direction for anesthesiology education, research, and clinical practice.

We collected high-impact papers, ranking in the top 10% in the field of anesthesiology and published from 2011 to 2020, by the InCites tool based on the Web of Science Core Collection. We analyzed the trends, locations, distribution of subject categories, research organizations, collaborative networks, and subject terms of these papers.

A total of 4,685 high-impact papers were included for analysis. The number of high-impact papers increased from 462 in 2011 to 520 in 2020. The paper with the highest value of category normalized citation impact (115.95) was published in Anesthesia and Analgesia in 2018. High-impact papers were mainly distributed in the subject categories of “Anesthesiology,” “Clinical Neurology,” “Neurosciences,” and “Medicine General Internal.” They were primarily cited in “Anesthesiology,” “Clinical Neurology,” “Neurosciences,” “Medicine General Internal,” and “Surgery.” Most of these high-impact papers came from the USA, UK, Canada, Germany, and Australia. The most productive institutions were the League of European Research Universities, Harvard University, University of Toronto, University of London, University of California System, and University Health Network Toronto. Research collaboration circles have been formed in the USA, UK, and Canada. Subject-term analysis indicated postoperative analgesia, chronic pain, and perioperative complications were high-interest topics, and COVID-19 became a new hot topic in 2020.

Conclusions

The current study provides a historical view of high-impact papers in anesthesiology in the past ten years. High-impact papers were mostly from the USA. Postoperative analgesia, chronic pain, and perioperative complications have been hot topics, and COVID-19 became a new topic in 2020. These findings provide references for education, research, and clinical practice in the field of anesthesiology.

Cette étude a été réalisée pour évaluer les tendances et fournir une orientation future à l’enseignement, la recherche et la pratique clinique en anesthésiologie.

Nous avons colligé des articles à fort impact, classés dans le top 10 % dans le domaine de l’anesthésiologie et publiés de 2011 à 2020, par l’outil InCites basé sur la Web of Science Core Collection. Nous avons analysé les tendances, les emplacements, la répartition des catégories de sujets, les organismes de recherche, les réseaux de collaboration et les termes des sujets de ces articles.

Au total, 4685 articles à fort impact ont été inclus pour analyse. Le nombre de manuscrits à fort impact est passé de 462 en 2011 à 520 en 2020. L’article ayant la valeur la plus élevée de l’impact normalisé des citations de catégorie (CNCI) (115,95) a été publié dans la revue Anesthesia and Analgesia en 2018. Les articles à fort impact ont été principalement distribués dans les catégories de thèmes « Anesthésiologie », « Neurologie clinique », « Neurosciences » et « Médecine générale interne ». Ils ont été principalement cités dans les catégories « Anesthésiologie », « Neurologie clinique », « Neurosciences », « Médecine générale interne » et « Chirurgie ». La plupart de ces articles à fort impact provenaient des États-Unis, du Royaume-Uni, du Canada, d’Allemagne et d’Australie. Les établissements les plus productifs étaient la League of European Research Universities, l’Université Harvard, l’Université de Toronto, l’Université de Londres, l’Université de Californie System et le University Health Network de Toronto. Des cercles de collaboration en recherche ont été formés aux États-Unis, au Royaume-Uni et au Canada. L’analyse des termes indiquait que l’analgésie postopératoire, la douleur chronique et les complications périopératoires étaient des sujets suscitant un fort intérêt, et la COVID-19 est devenue un nouveau sujet brûlant en 2020.

La présente étude propose une vue historique des articles à fort impact en anesthésiologie au cours des dix dernières années. Les manuscrits à fort impact provenaient principalement des États-Unis. L’analgésie postopératoire, la douleur chronique et les complications périopératoires ont été des sujets d’actualité, et la COVID-19 est devenue un nouveau sujet en 2020. Ces résultats fournissent des références pour la formation, la recherche et la pratique clinique dans le domaine de l’anesthésiologie.

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Anesthesiology is a key discipline that ensures safety and comfort during invasive procedures, improves surgical work efficiency, and coordinates the relationships among various disciplines. 1 , 2 , 3 In recent years, significant progress has been made in anesthesiology, involving perioperative organ protection, perioperative anesthesia management for the elderly, development of new anesthetic drugs, and basic research into the mechanisms of anesthesia and chronic pain. 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 Especially during the COVID-19 pandemic, anesthesiologists played important roles 12 , 13 , 14 and undoubtedly saved many lives. Anesthesiology practice has been improved by the development of new anesthetics and monitoring equipment, 3 a better understanding of the physiologic changes during surgery and anesthesia, 15 and evidence of the clinical benefits of optimal perioperative management strategies. 16 Because of its multidisciplinary nature, anesthesiology research can be applied to neuroscience, surgery, cardiovascular medicine, respirology, critical care, and other fields.

Literature analysis using large bibliometric databases 17 can qualitatively and quantitatively evaluate current research trends, 18 , 19 to determine future research directions and provide policy guidance for decision-makers. 20 Several studies have analyzed literature in the field of anesthesiology. Robert et al . 21 analyzed the literature on pain from 1976 to 2007 and traced the evolution of the scientific literature on pain over 30+ years; they concluded that the evolution and explosion of pain research were rapid and caused substantial changes in the landscape of the contributing countries and the scientific journals in the pain field. Chen et al . 22 reported research trends in anesthesiology from 1995 to 2004 by analyzing 64,199 articles with 1,084,491 citations. They found that the number of articles increased slightly in the second decade. More than 45% of papers were published by the top five journals, and most publications originated from North America and European countries. It helped clinicians and researchers to understand the anesthesiology research activities in the second decade. Chen et al . 23 reported global publication trends in anesthesiology from 1999 to 2018 and argued that more high-quality research should be carried out in low and middle-income countries. Although these studies determined progress in anesthesiology research over specific periods, they did not identify high-impact papers. As a consequence, the research trends of high-impact anesthesiology papers are still unknown.

To analyze high-impact papers in other fields, previous studies have collected and analyzed the top 1% or 10% papers using the InCites ™ tool based on the Web of Science (WOS) Core Collection (Clarivate ™ , London, UK) and provided important evidence and references for research or education in nursing management, 24 pharmacology, and pharmacy. 25 Nevertheless, no such study has been performed in anesthesiology. Therefore, we designed a cross-sectional study to analyze the high-impact papers in anesthesiology.

Study design and ethical involvement

This was a cross-sectional study based on previously published studies, and institutional review board approval was not required. 25

Inclusion and exclusion criteria

The following inclusion criteria were used: 1) study was in the field of anesthesiology according to the InCites tool based on WOS Core Collection; 2) type of study was an article or review; 3) study was published between 2011 and 2020; 4) paper was high impact (defined according to a previous study, 24 using “% Documents in Top 10%” in the InCites tool, which meant the percentage of the top 10% of publications based on citations by category, year, and document type). The following exclusion criteria were used: 1) the study was not found in the WOS Core Collection and 2) data could not be found in the database.

Literature search and data extraction

We conducted the literature search on 25 October 2021, using the InCites tool to find high-impact papers in the field of anesthesiology, 25 and the search was updated on 7 July 2022. A total of 4,685 studies were identified. All data were downloaded by the InCites tool. The following information was extracted: Category Normalized Citation Impact (CNCI), title of article, journal name, location (country/region), and organization. The CNCI of a document was calculated by dividing the actual number of citing items by the expected citation rate for documents with the same document type, publication year, and subject area. When a document was assigned to more than one subject area, an average of the ratios of the actual to expected citations was used. 26 The CNCI values were used to represent the citation performance on the world average—a CNCI value of more than 1 meant the impact was higher than the global average. 26 To find the information of country or institution, the location or institution filter was used, respectively.

Statistical analysis and visualization analysis

The statistical and visualization analyses were carried out using Numbers software (Apple Inc., Cupertino, CA, USA) and VOS viewer (Leiden University, Leiden, The Netherlands). The Numbers software was used to draw figures to show the numbers of studies and the trends of studies. 25 VOS viewer was applied to construct and visualize bibliometric networks. The networks might include journals, researchers, or individual publications, and they could be built based on citation, bibliographic coupling, co-citation, or co-authorship relations. 27 The CNCI values, trends in the number and citation impact, subject areas, countries, institutions, collaborative networks, and subject terms were analyzed.

Trends of high-impact papers in anesthesiology

High-impact papers in the field of anesthesiology increased from 462 in 2011 to 520 in 2020. The average CNCI value of high-impact papers was 4.50, which ranked about 139 among the 254 research areas (Electronic Supplementary Material [ESM] eTable 1). It decreased from 4.69 in 2011 to 4.21 in 2017 and then increased to 4.38 in 2019. Finally, the CNCI value increased substantially in 2020, reaching 5.46 (Fig. 1 ). The characteristics of the top ten CNCI value papers and top ten cited papers are shown in ESM eTable 2. The study with the highest CNCI value was a methodological study entitled Correlation coefficients: appropriate use and interpretation, which was published in Anesthesia and Analgesia in 2018, 28 with a total of 1,176 citations and a CNCI value of 115.95. The publication with the second highest CNCI value was a guideline entitled Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anesthetists , 29 which was published in Anaesthesia in 2020, with a total of 335 citations and a CNCI value of 75.75. The most cited publication was a review entitled Central sensitization: implications for the diagnosis and treatment of pain, 30 which was published in Pain in 2011, with a total of 2,010 citations and a CNCI value of 40.52. The journals with the highest impact factors were The Lancet , The New England Journal of Medicine (NEJM), JAMA, and The BMJ , which published 15, four, 19, and 14 high-impact papers, respectively.

Number and citation impact of high-impact papers in anesthesiology from 2011 to 2020. CNCI = Category Normalized Citation Impact

Subject categories of high-impact papers

When searching for the 4,685 papers via WOS Core Collection, only 4,682 were found, including 3,994 articles (reports of research on original works) and 688 reviews (renewed studies of material previously studied). The average and median citation times for articles were 72 and 57, respectively. The average and median citation times for reviews were 120 and 89, respectively. The results suggested that the reviews were cited more than the articles. The 4,682 high-impact papers could be divided into 15 WOS subject categories (ESM eFig. 1). After “Anesthesiology,” “Clinical Neurology” had the highest number of papers ( n = 1,475), followed by “Neurosciences” ( n = 1,126) and “Medicine General Internal” ( n = 331). The 4,582 high-impact papers were cited by a total of 179,117 papers, which were distributed in more than 100 WOS subject categories. The 15 most frequently cited subject categories are shown in ESM eFig. 2. “Anesthesiology” accounted for the largest number of papers, with 39,402 citing papers. The citation impact of these high-impact papers extended to “Clinical Neurology” ( n = 19,835), “Neurosciences” ( n = 17,944), “Medicine General Internal” ( n = 15,170), and “Surgery” ( n = 12,688).

Location of high-impact papers

The locations that published the most high-impact papers in the field of anesthesiology were the USA, UK, Canada, and Germany (ESM eTable 3).

Organization of origin of high-impact papers

The organizations that published the most high-impact papers in anesthesiology were the League of European Research Universities, Harvard University, University of Toronto, University of London, University of California System, and UDICE-French Research Universities (ESM eTable 4). The top 15 organizations and their CNCI values are shown in Fig. 2 and ESM eTable 4, respectively.

Numbers of high-impact papers in anesthesiology and CNCI values of the top 15 production institutions. APHP = Assistance Publique Hopitaux Paris; Inserm = Institut National de la Sante et de la Recherche Medicale, National Institute of Health and Medical Research in France; CNCI = Category Normalized Citation Impact; LERU = League of European Research Universities; UDICE = French Research Universities

Cooperation network of institutions of high-impact papers

Figure 3 shows the network of cooperation among institutions with the highest number of high-impact papers in anesthesiology from 2011 to 2020. Each color represents a cluster, which means that there was cooperation between institutions with the same color. The size of each node represents the number of papers, and the connecting line indicates cooperation. The network map revealed that there were six leading collaborative circles among institutions, which were mainly universities from the same country and region. Specifically, the largest node was the university groups from the USA and Canada (at the above corner), including the University of Toronto, Stanford University, and Duke University. The top collaborative circles were mainly in the USA, UK, and Canada (ESM eFig. 3).

Map of collaborative networks among institutions of high-impact papers

Subject-term heatmap of high-impact papers

We used VOS viewer to perform natural language processing on the titles and abstracts of the 4,682 high-impact papers and divide the processed subject terms and phrases into clusters. The warmer the color of topic terms on the heatmap, the higher the frequency of terms appeared in the literature. In the heatmap of all studies (Fig. 4 ), three main hot research topics were found. Postoperative analgesia was the first hotspot, including “analgesia,” “block,” “ultrasound,” “opioid consumption,” “pain score,” “Visual Analogue Scale,” and “vomiting.” Pain, especially chronic pain, was the second hot research topic, including “pain,” “chronic pain,” “pain intensity,” “pain severity,” “pain modulation,” “depression,” and “disability.” Perioperative complications was the third research hotspot, including “complications,” “mortality,” “delirium,” “cardiac surgery,” “failure,” “discharge,” and “comorbidity.”

Subject terms heat map of high-impact papers in anesthesiology

To evaluate the latest progress, we performed a subject-term heatmap analysis on papers published in 2020. From the heatmap (ESM eFig. 4), COVID-19 was found to be the new research hotspot, which included “COVID,” “pandemic,” “recommendation,” “risk factor,” and “coronavirus disease.”

To evaluate the difference in progress between article types, we performed a further analysis based on the article and review. In the heatmap of all articles (ESM eFig. 5), three main hot research topics, including postoperative analgesia, pain, and perioperative complications, were found. In the heatmap of reviews (ESM eFig. 6), postoperative analgesia, pain, perioperative complications, and COVID-19 were the main research topics.

To evaluate the most high-impact papers, we performed a further analysis based on the top 1% papers. A total of 482 papers were included. In the heatmap (ESM eFig. 7), four main hot research topics were included, which included postoperative analgesia, pain, perioperative complications, and COVID-19.

In the present study on high-impact papers in anesthesiology over the past ten years, we hope it could provide reference for future education, research, and clinical practice in anesthesiology. We found that the number of high-impact papers published each year varied from 462 in 2011 to 443 in 2019 and significantly increased in 2020. The increased number of papers in 2020 might be due to the COVID-19 pandemic because anesthesiologists played important roles in fighting COVID-19. The increasing trend of high-impact papers in 2020 was similar to the results from previous pharmacology and pharmacy studies, 25 indicating that COVID-19 had influenced global studies.

In this study, we compared a few top CNCI value papers and top-cited papers. The results show that the papers with high CNCI values were all published in journals of the Anesthesiology category, and four of them were published in 2020 with the COVID-19 topic. The top ten cited papers were published from 2011 to 2018 and were mainly published in anesthesiology journals, and their CNCI values ranged from 15 to 115. The papers with the highest impact were published in the top four medical general journals— Lancet , NEJM , JAMA, and BMJ published 15, four, 19, and 14 papers, respectively. Interestingly, the top ten cited papers were not from the top impact-factor journals, which indicate that the research published in anesthesiology journals could be both high impact and highly cited. It was particularly encouraging that seven of the top ten cited papers were published in journals with an impact factor below 10. 24 , 25 This observation indicates a wide range of citation models in individual journals. Therefore, the impact factor of a journal should not always be used to assess the feature of citation and the impact of papers.

In the study, we analyzed the interactions between different subject categories by papers and their citations. All high-impact papers were from 15 WOS subject categories and cited by more than 100 WOS subject categories, which suggests a strong influence from the anesthesiology high-impact papers. Anesthesiology is a multidisciplinary category that has attracted attention from various categories. 23 Besides “Anesthesiology,” “Clinical Neurology” and “Neurosciences” were the top citing categories, indicating that the most important progress in anesthesiology has been made in the fields of “Clinical Neurology” and “Neuroscience.”

The results revealed that League of European Research Universities, Harvard University, University of Toronto, University of London, University of California System, and University Health Network Toronto were leading organizations in anesthesiology. Top-level cooperation was mainly based in the USA, Canada, and the UK, which implies that researchers collaborated more inside their own countries. It is necessary to conduct research cooperation with international institutions. The results show that the USA, UK, Canada, Germany, and Australia published the most high-impact papers, consistent with a previous study. 23 It suggested that the high-impact papers had always been from high-income countries, and not so many papers were from low- and middle-income countries because low- and middle-income countries might lack funds, skills, and technology, leading to limited research level and ability. It is necessary to improve research ability and increase funds and training to reduce inequality, and promote publications from low- and middle-income countries.

To analyze the difference between types of studies, we performed a further analysis based on the types of published papers. For articles, we found three main hot research topics, which were almost the same as the total analysis; for reviews, COVID-19 emerged as the new hot topic, which was slightly different from articles, suggesting that COVID-19 had a high impact on the field. In addition, we performed a further analysis of the most high-impact papers (top 1% papers), and the results were almost the same as the data in 2020, which suggests the high impact of COVID-19.

There are several limitations to this study. First, the search was based on the “Anesthesiology” category, which might have missed some studies. Second, we only searched published papers from 2011 to 2020. Papers published before and after this period were excluded so that some other high-impact papers might have been missed. Another limitation was the inherent bias in the high-impact papers, which referred to the top 1% or 10% papers in a certain research field. 24 , 25 The number of citations of papers accumulates over time, and thus, some papers might not be high impact at present, but they could be after a few months. This could have led to inaccuracy in analysis. Lastly, the study was based on the InCites tool. Misclassification that could not be excluded from research in some papers might also have led to inaccurate results.

Overall, the current research provides a historical view of the research progress in anesthesiology over the past ten years. High-impact papers were mostly from the USA. Postoperative analgesia, pain, and perioperative complications were topics of high interest, and COVID-19 emerged as a new hot topic in 2020. This research provides a reference for future education, research, and clinical practice in anesthesiology.

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Author contributions

Yonggang Zhang designed the study and edited the manuscript; Lingmin Chen searched for the data, analyzed the data, and drafted the manuscript; and Nian Li analyzed the data and drafted the manuscript.

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This manuscript was edited by Enliven Co. (Beijing, China).

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Funding statement.

This study was supported by the National Natural Science Foundation of China (No: 82001130), The Post-Doctoral Research Project of Sichuan University (2021SCU12001), and The Post-Doctoral Research Project of West China Hospital of Sichuan University (No. 19HXBH071).

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This submission was handled by Dr. Philip M. Jones, Deputy Editor-in-Chief, Canadian Journal of Anesthesia/Journal canadien d’anesthésie .

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Lingmin Chen PhD

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Nian Li PhD

Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China

Yonggang Zhang PhD

Department of Periodical Press and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China

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Chen, L., Li, N. & Zhang, Y. High-impact papers in the field of anesthesiology: a 10-year cross-sectional study. Can J Anesth/J Can Anesth 70 , 183–190 (2023). https://doi.org/10.1007/s12630-022-02363-5

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Published : 23 November 2022

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DOI : https://doi.org/10.1007/s12630-022-02363-5

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Circulation 60,475 • Volume 15, No. 3 • Fall 2000

ASA Annual Meeting Features Many, Varied Patient Safety Topics

Visit the APSF Booth in the ASA Meeting Exhibit Area.

Patient safety continues its prominent position as a presentation topic that has grown to a become a permanent fixture of the American Society of Anesthesiology Annual Meeting. This year’s assembly is in San Francisco from Saturday, October 14 through Wednesday, October 18.

Among the many relevant Saturday Refresher Course Lectures, Dr. B. Cullen will present “Drug Interactions for the Anesthesiologist” (# 161), Dr. C. Hagberg covers “Current concepts in the Management of the Difficult Airway” (# 163) and Dr. S. Hall presents his classic “The Child with a Difficult Airway: Recognition and Management” (# 165). On Sunday, notable among many germane topics, Dr. M. Bishop will speak on “Bronchospasm: Successful Management” (# 272). Also, Dr. Stephen Small of the University of Chicago introduces an important new topic to the Refresher Course series with his lecture, “Reframing the Question of Human Error: Tools to Navigate the Next Era in Anesthesia Safety” (# 263). After the lunch break, the same lecture hall hosts a sequence of three safety-related presentations: Dr. M. Warner on “Perioperative Neuropathies: Current Thoughts on Etiology and Prevention” (# 264), Dr. R. Caplan on “The ASA Closed Claims Project: Lessons Learned” (# 265), and Dr. J. Eichhorn on “Risk Management in Anesthesia” (# 266).

In the Clinical Update Program lunchtime lecture series, Dr. R. Stoelting speaks about “‘NPO’ and Aspiration: New Perspectives” (# 432) on Tuesday at 12:40 p.m.; Dr. J. Eisenkraft covers “Problems with Anesthesia Gas Delivery Systems” (# 511) Wednesday at 11:30 a.m.; and Dr. G. Levinson presents “Obstetric Standards: What’s Old? What’s New?” (# 522) Wednesday at 12:40 p.m.

Among the numerous interesting Panel Presentations, one on Tuesday afternoon is especially relevant. Dr. L. Fleisher will host a panel entitled “Risk of Anesthesia: Can We Detect and Prevent Rare Outcomes?” (2-4 p.m., Moscone Room 131). It includes Dr. F. Cheney on the “ASA Closed Claims Project,” Dr. J. Morray on “Pediatric Perioperative Cardiac Arrest Registry,” Dr. J. Silber on “Failure to Rescue,” and Dr. Fleisher on “Outpatient Location of Care: Analysis of Medicare Claims.” Also, on Wednesday afternoon, as part of the panel “Anesthesia for Office-Based Surgery: The Surgery May Be Cosmetic but the Anesthesia Runs Deep,” Dr. T. Joas will present “Public Safety – How and Why Did Politicians get involved in OBA?”

Hands on for Safety

The Workshop series, always an extremely popular component of the ASA meeting because of the “hands-on” experiences offered to participants, contains many skill topics directly related to patient safety, such as fiberoptic-guided intubation (adult and pediatric), difficult airways in general (also adult and pediatric), and detecting and troubleshooting malfunctions in anesthesia delivery systems.

The section of the Scientific Papers presentations focusing on safety is “Practice Management & Patient Safety” and features four sessions during the meeting which incorporate 76 individual scientific papers.

A poster-discussion session Monday morning has been devoted to two topics receiving increasing recent interest: renal effects of inhalation anesthetics and also carbon dioxide absorbers. Potential deleterious impact of low-flow inhalation anesthesia with sevoflurane is the subject of four papers. Likewise, production of Compound A or carbon monoxide due to interactions with CO 2 absorbent also will have four abstracts presented and discussed by both moderators and the audience.

Also Monday morning is a regular poster session that includes such varied topics as: the physiologic changes among morbidly obese patients having laparoscopic surgery, LMA use in known difficult airways and in resuscitations, risk factors for postoperative neuropathy and also the point that males seem more susceptible that females, mechanism of brain damage in anesthesia-related adverse events, ethics in cost-containment research, inadequate reporting of a patient’s difficult airway experience or even cardiac arrest causing preventable future problems, lack of oxygen use in postop transport, variations in “the real anesthesia mortality rate,” comparison of perioperative morbidity in third-world vs. industrialized country statistics, embolism during total hip surgery, a new analysis of dental injuries associated with anesthesia, an analysis of visual loss associated with surgery, and stability studies of various propofol emulsions.

The other large regular poster session is Tuesday afternoon. Again, among the wide variety of topics covered are: safety of immediate extubation after AAA surgery, the safety of pediatric sedation services, a safety analysis of over a million elderly outpatient cases comparing hospital vs. non-hospital locations, confirmation that ASA physical status classification is predictive of adverse outcome rate and severity, the timetable for practice re-entry for chemically dependent anesthesiologists, efficacy of air-elimination devices in rapid high-volume fluid infusers, and, finally, an assessment of patients’ preoperative spiritual needs based on the observation that the majority of patients desire to pray before anesthesia for surgery.

The final poster-discussion session is Wednesday afternoon and includes five papers on preoperative testing, including one on using diagonal earlobe creases as a sign of ischemic heart disease and one on more classic preop cardiac stress testing. The other topic is blood product usage and papers cover the issues of safely reducing transfusion in vascular surgery, preoperative prediction of transfusion needs, and reduction of transfusion associated with the new endoluminal AAA treatments.

These previews highlight merely some of the safety-related presentations at the ASA meeting and a full schedule can be found in the Annual Meeting Program.

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