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Effect of esketamine on the ED 50 of propofol for successful insertion of ureteroscope in elderly male patients: a randomized controlled trial

Propofol is effective and used as a kind of routine anesthetics in procedure sedative anesthesia (PSA) for ureteroscopy. However, respiratory depression and unconscious physical activity always occur during pr...

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Dexmedetomidine versus remifentanil in nasal surgery: a systematic review and meta-analysis

Nasal surgeries, addressing anatomical variations for form and function, require careful anesthesia administration, including dexmedetomidine and remifentanil. This meta-analysis evaluates their safety and eff...

Effect of intramuscular diazepam infusion on herpes zoster-related pain in older patients: a randomized, double-blind, placebo-controlled trial

This study evaluated the effectiveness, psychological effects, and sleep quality using intramuscular diazepam infusion compared with placebo in patients with herpes zoster (HZ)-related pain.

Evaluation of the Erector spinae plane block for postoperative analgesia in laparoscopic ventral hernia repair: a randomized placebo controlled trial

The Erector spinae plane block (ESPB) reduces postoperative pain after several types of abdominal laparoscopic surgeries. There is sparse data on the effect of ESPB in laparoscopic ventral hernia repair. The p...

A prospective, randomized, single-blinded study comparing the efficacy and safety of dexmedetomidine and propofol for sedation during endoscopic retrograde cholangiopancreatography

Balanced propofol sedation is extensively used in endoscopic retrograde cholangiopancreatography (ERCP), but sedation-related adverse events (SRAEs) are common. In various clinical settings, the combination of...

Characteristics that increase the risk for pain on propofol injection

Propofol for anesthesia has become increasingly popular for endoscopic procedures. However, pain on propofol injection (POPI) remains an issue with administration. The primary endpoint of this study was to ide...

High-flow nasal cannula oxygen reduced hypoxemia in patients undergoing gastroscopy under general anesthesia at ultra-high altitude: a randomized controlled trial

Hypoxemia can occur in people at ultra-high altitude (above 3500 m) even at rest, and patients undergoing gastroscopy under general anesthesia have higher risk of hypoxemia. Supplementary oxygen via standard n...

Does higher performance in a national licensing examination predict better quality of care? A longitudinal observational study of Ethiopian anesthetists

Ethiopia made a national licensing examination (NLE) for associate clinician anesthetists a requirement for entry into the practice workforce. However, there is limited empirical evidence on whether the NLE sc...

Feasibility of continuous non-invasive delivery of oxygen monitoring in cardiac surgical patients: a proof-of-concept preliminary study

Oxygen delivery (DO 2 ) and its monitoring are highlighted to aid postoperative goal directed therapy (GDT) to improve perioperative outcomes such as acute kidney injury (AKI) after high-risk cardiac surgeries asso...

The influence of dexmedetomidine added to ropivacaine for transversus abdominis plane block on perioperative neurocognitive disorders after radical colorectal cancer surgery: randomized, double-blind, controlled trial

Perioperative Neurocognitive Disorders (PND) is a common neurological complication after radical colorectal cancer surgery, which increases adverse outcomes. So, our objective is to explore the influence of de...

Effects of esketamine on postoperative fatigue syndrome in patients after laparoscopic resection of gastric carcinoma: a randomized controlled trial

Despite the implementation of various postoperative management strategies, the prevalence of postoperative fatigue syndrome (POFS) remains considerable among individuals undergoing laparoscopic radical gastrec...

Preoperative investigation practices for elective surgical patients: clinical audit

The findings of pre-operative investigations help to identify risk factors that may affect the course of surgery or post-operative recovery by contributing to informed consent conversations between the surgica...

Correction: Mild increases in plasma creatinine after intermediate to high-risk abdominal surgery are associated with long-term renal injury

The original article was published in BMC Anesthesiology 2021 21 :135

Application of ultrasound-guided single femoral triangle and adductor canal block in arthroscopic knee surgery: a prospective, double-blind, randomized clinical study

To compare the difference in analgesic effect between femoral triangle block (FTB) and adductor canal block (ACB) during arthroscopic knee surgery.

Efficacy of bougie first approach for endotracheal intubation with video laryngoscopy during continuous chest compression: a randomized crossover manikin trial

Endotracheal intubation is challenging during cardiopulmonary resuscitation, and video laryngoscopy has showed benefits for this procedure. The aim of this study was to compare the effectiveness of various int...

Ultrasound guided quadratus lumborum block versus interlaminar epidural block for analgesia in pediatric abdominal surgery: a randomized controlled trial

Although the efficacy and safety of epidural block (EB) are fairly high, complications such as inadvertent dural puncture may limit its use. Ultrasound-guided quadratus lumborum block (QLB) is a relatively new...

Efficacy and safety of video double-lumen tube intubation in lateral position in patients undergoing thoracic surgery: a randomized controlled trial

Video double-lumen tube (VDLT) intubation in lateral position is a potential alternative to intubation in supine position in patients undergoing thoracic surgery. This non-inferiority trial assessed the effica...

Mortality and cardiac arrest rates of emergency surgery in developed and developing countries: a systematic review and meta-analysis

The magnitude of the risk of death and cardiac arrest associated with emergency surgery and anesthesia is not well understood. Our aim was to assess whether the risk of perioperative and anesthesia-related dea...

The effect of deep and awake extubation on emergence agitation after nasal surgery: a randomized controlled trial

Post-anesthetic emergence agitation is common after general anesthesia and may cause adverse consequences, such as injury as well as respiratory and circulatory complications. Emergence agitation after general...

Association between mechanical power during one-lung ventilation and pulmonary complications after thoracoscopic lung resection surgery: a prospective observational study

The role of mechanical power on pulmonary outcomes after thoracic surgery with one-lung ventilation was unclear. We investigated the association between mechanical power and postoperative pulmonary complicatio...

Establishment and validation of a predictive model for tracheotomy in critically ill patients and analysis of the impact of different tracheotomy timing on patient prognosis

In critically ill patients receiving invasive mechanical ventilation (IMV), it is unable to determine early which patients require tracheotomy and whether early tracheotomy is beneficial.

The 90% effective dose (ED90) of remimazolam for inhibiting responses to the insertion of a duodenoscope during ERCP

Compared to midazolam, remimazolam has a faster onset and offset of hypnotic effect, as well as cardiorespiratory stability, this study aims to determine the 90% effective dose (ED90) of remimazolam to inhibit...

Anaesthesia management of a patient with Bethlem Myopathy for elective tonsillectomy: a case report

Bethlem Myopathy is a collagen VI-related myopathy presenting as a rare hereditary muscular disorder with progressive muscular weakness and joint contractures. Despite its milder clinical course relative to ot...

Effects of perioperative low-dose naloxone on the immune system in patients undergoing laparoscopic-assisted total gastrectomy: a randomized controlled trial

Low immune function after laparoscopic total gastrectomy puts patients at risk of infection-related complications. Low-dose naloxone (LDN) can improve the prognosis of patients suffering from chronic inflammat...

Indirect calorimetry directed feeding and cycling in the older ICU population: a pilot randomised controlled trial

Older critically ill patients experience rapid muscle loss during stay in an intensive care unit (ICU) due to physiological stress and increased catabolism. This may lead to increased ICU length of stay, delay...

Effect of lidocaine on intraoperative blood pressure variability in patients undergoing major vascular surgery

Dynamic fluctuations of arterial blood pressure known as blood pressure variability (BPV) may have short and long-term undesirable consequences. During surgical procedures blood pressure is usually measured in...

Anesthetic management for cesarean section in two parturient with ascending aortic aneurysm: a case-based discussion

The anesthetic management of parturients with ascending aortic aneurysm for cesarean section can be particularly challenging, primarily because of increased risk for aortic dissection or aneurysm rupture.

Remote ischemic conditioning may improve graft function following kidney transplantation: a systematic review and meta-analysis with trial sequential analysis

Remote ischemic conditioning (RIC) has the potential to benefit graft function following kidney transplantation by reducing ischemia-reperfusion injury; however, the current clinical evidence is inconclusive. ...

Substance specific EEG patterns in mice undergoing slow anesthesia induction

The exact mechanisms and the neural circuits involved in anesthesia induced unconsciousness are still not fully understood. To elucidate them valid animal models are necessary. Since the most commonly used spe...

Airway management and pulmonary aspiration during surgical interventions in pregnant women in the 2nd/3rd trimester and immediate postpartum – a retrospective study in a tertiary care university hospital

Pregnancy is associated with an increased risk of pulmonary aspiration during general anaesthesia, but the incidence of this complication is not well defined.

My anesthesia Choice-HF: development and preliminary testing of a tool to facilitate conversations about anesthesia for hip fracture surgery

Patients often desire involvement in anesthesia decisions, yet clinicians rarely explain anesthesia options or elicit preferences. We developed My Anesthesia Choice-Hip Fracture, a conversation aid about anest...

Role of preoperative zinc, magnesium and budesonide gargles in Postoperative Sore Throat (POST) - a randomised control trial

Post-operative sore throat (POST) has an incidence ranging from 21 to 80%. To prevent the development of POST, several pharmacological measures have been tried. Aim of this study was to compare the efficacy of...

Effect of intravenous anesthetic drugs on fertilization rate in oocyte retrieval

The purpose of this study was to investigate the effects of intravenous anesthetic drugs on fertilization rate in subjects receiving oocyte retrieval by assisted reproduction technology (ART).

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 ...

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...

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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' .)

REGIONAL ANESTHESIA

Anti-factor Xa levels 24 hours after the last therapeutic enoxaparin dose (April 2024)

Guidelines recommend waiting 24 hours after a therapeutic dose of low molecular weight heparin (LMWH) before performing neuraxial anesthesia, to minimize the risk of spinal epidural hematoma (SEH). However, anti-factor Xa levels (which test LMWH activity) may still be elevated 24 hours after the last dose. In a study of 103 patients taking therapeutic dose enoxaparin , 23 percent had an anti-factor Xa level ≥0.2 international units/mL at ≥24 hours after the last dose [ 10 ]. The implications of these findings are unclear, as a safe anti-factor Xa level for performing neuraxial procedures has not been determined and there has not been a noticeable increase in SEH in patients who have withheld LMWH according to current guidelines. (See "Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication", section on 'Therapeutic LMWH' .)

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 [ 11 ]. 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) [ 12 ]. 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 [ 13 ]. 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 [ 14 ]. 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' .)

• 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.
• Henshaw DS, Edwards CJ, Dobson SW, et al. Evaluating residual anti-Xa levels following discontinuation of treatment-dose enoxaparin in patients presenting for elective surgery: a prospective observational trial. Reg Anesth Pain Med 2024; 49:94.
• 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.

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Acknowledgments

Competing interests, anesthesiology: reflecting and leading.

Accepted for publication July 30, 2021.

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Evan D. Kharasch; Anesthesiology: Reflecting and Leading. Anesthesiology 2021; 135:551–554 doi: https://doi.org/10.1097/ALN.0000000000003958

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“A nesthesiology continues to publish the highest-quality clinical and basic scientific research in the field, to create trusted evidence, spanning from discovery to practice.”

Image: A nesthesiology icon.

It has become my custom as Editor-in-Chief to publish in July, at the start of the new academic year, an essay of past reflection and journal plans for the upcoming year. Astute readers will note this is not July. Last year’s message reflected on the COVID-19 pandemic of 2019 to ???, with no knowledge of when it would end. 1   For this July, with implementation of the swiftly developed and extremely efficacious vaccines and innovative patient management and therapeutic strategies, there was optimistic hope to close out the story as the pandemic of 2019 to 2021. However, with some early signals of resurgence due to the highly contagious delta variant, publication of this editorial was paused, hoping that the signal was just transitory and victory could be announced and celebrated, along with some return to normalcy among critical care practitioners, operating room denizens, and investigators. Unfortunately, those signals were real, and we are in for more, with vaccination resistance, increasing disease transmission, and once-falling caseloads now reversed and climbing. No longer somewhat normalized, systems are again changing rapidly, including just-updated Centers for Disease Control guidance that even fully vaccinated people return to wearing masks when indoors, new mask mandates, expanded testing, and required vaccinations by schools, healthcare institutions, and employers.

Last year, Anesthesiology mobilized an extraordinary response to unprecedented circumstances, leading the specialty. In February 2020, we published a special online suite of COVID-19–related articles, in partnership with clinicians in China, including firsthand information, scholarly reviews, clinical protocols, and recommendations on the ongoing pandemic. 2   This collection has grown beyond the original seven articles published and two accompanying podcasts. It now includes numerous additional articles, including a review on COVID-19 and personal protective equipment, an original investigation on aerosol retention characteristics of barrier devices, and a photo essay that demonstrates the humanity of response to COVID-19 around the world. A third podcast, “COVID-19: Challenges of Hemostasis and Coagulopathy,” featuring Drs. Jerrold H. Levy and Jean M. Connors, was recently added to the collection. All are available on the Journal website, and we will continue to add to our COVID-19 offerings as needed. In addition, the 30th annual Anesthesiology Journal Symposium, at the 2021 American Society of Anesthesiologists (ASA) Annual Meeting, to be led by Journal Editors Dr. Levy and Dr. Martin London, is themed “SARS-CoV-2 and COVID-19: New Paradigms and Challenges for Anesthesiologists.”

The coronavirus pandemic continues to have an extraordinary influence on scholarly publishing. As of April 28, 2020, PubMed listed more than 7,300 COVID-19 articles. Little more than one year later, July 27, 2021, there were more than 160,600 articles!

Anesthesiology continues to publish the highest-quality clinical and basic scientific research in the field, to create trusted evidence, spanning from discovery to practice. It leads and influences the field through publication of original research, reviews, and editorials. Special articles have addressed the role of anesthesiology in health policy, burnout in anesthesiologists, levels of evidence and clinical practice guidelines, and provision of anesthesia care in space. Anesthesiology continues to attract and publish high-quality original investigations as evidenced by the 14% increase in original investigation submissions from 2019 to 2021. Tables 1 and 2 list the 20 most viewed articles in 2020 that were published in 2019 and 2020.

2019 Anesthesiology Articles Most Viewed in 2020

2020 Anesthesiology Articles Most Viewed in 2020

In addition to striving to continuously increase the quality and content of published articles, Anesthesiology endeavors to disseminate journal content as broadly as possible, through multiple channels of communication, to maximize our reach. This includes traditional scholarly publishing, as well as alternative methods and partnerships. For example, the Pain Research Forum, an online publication of the International Association for the Study of Pain, features one Anesthesiology article each month as its Editors’ Pick. So too do the ASA’s Monday Morning Outreach and the ASA Monitor. The Journal social media program has grown to include 12 social media ambassadors to engage and drive discussions on social media and recommendations for new initiatives. In 2020, the Journal’s Twitter account saw a 32% increase in followers, a 45% increase in mentions, a 70% increase in retweets, an 88% increase in engagements, and a 93% increase in likes. In October 2020, we launched a Journal-branded Instagram account that now has more than 1,100 followers. Follow Anesthesiology on Twitter (@_Anesthesiology), Facebook ( https://www.facebook.com/ASAanesthesiology ), and Instagram (@anesthesiology_journal). For content distribution, Anesthesiology launched a refreshed website in September 2020, with improved access to journal articles and other content, enhanced search functionality, new trending topic alerts, and new viewer options for split-view page layout, enabling easier navigation between text and figures/tables. To provide better service to our authors, the new website features an Author Resource Center, which includes comprehensive submission instructions, information regarding peer review, social media dissemination, journal metrics, and scientific integrity. Website usage continues to increase after the new launch. Overall page views increased 4% in the first quarter of 2021 compared to the fourth quarter 2020, as did Journal visits. International visitors comprised 54% of all traffic; thus, Anesthesiology reach extends far beyond the United States, as we continue being an international journal.

Anesthesiology strives to bring value to ASA members; all anesthesiologists, critical care physicians, pain physicians, certified registered nurse anesthetists, and certified anesthesiologist assistants worldwide; and investigators in anesthesiology and biomedical science most broadly. We want to know how we are doing. How are our metrics? What we have learned from them is gratifying and speaks to the quality of Journal content and the contributions of our authors, editors, reviewers, and staff. Thank you.

The ASA conducts a periodic survey of its members. We were thrilled to see how the Journal ranked in both importance to members and their satisfaction with the content we publish. Of all the ASA offerings and activities, Anesthesiology (and the ASA website) was by far the most utilized, and 87% of respondents were satisfied or extremely satisfied with the Journal. Of all the factors contributing to ASA member satisfaction, Anesthesiology and the ASA practice guidelines it publishes were ranked highest. Staying informed on the latest clinical information ( e.g. , Anesthesiology , practice guidelines) was the top-most reason for maintaining ASA membership. That increased more with years in the profession and was similar between members in academic or private practice. With regard to ASA investing on behalf of the field of anesthesiology, offering access to high-quality education and access to novel clinical research in anesthesiology were listed as two of the three most important reasons. This information shows that Journal scientific content is highly valued by ASA members and demonstrates Journal value to the organization from a membership point of view, beyond usage and satisfaction.

Another metric is the 2-yr Journal Impact Factor, which is controversial 3   and about which I have written and cautioned previously. 4   This well known but less well understood number is the ratio of all citations to journal content (research, reviews, editorials, letters, etc.) to citable articles (typically research and reviews) in the previous 2 yr. The just-released 2020 Anesthesiology Impact Factor is 7.892, representing 33,319 citations to Journal content and 436 unique contributing authors. Perhaps more importantly, and as a measure of our enduring importance and foundational value, are the 5-yr Impact Factor of 8.139 and the citation half-life of 11.4 yr. These metrics are yet again the highest in Journal history.

Nonetheless, as is recognized, the Impact Factor can be “gamed,” and certain journals do so voraciously. One approach is excessive self-citation, in which journal content cites other articles in that same journal, such as through author coercion (requiring authors to cite articles in that journal as a condition of manuscript acceptance) and profligate letters to the editor that cite the journal. Another approach is to publish research as correspondence, which accrues citations (raising the numerator) but does not count as “citable items” (reducing the denominator), thereby increasing the Impact Factor ratio. In recognition of that, Clarivate, the company that publishes the Impact Factor, also publishes an Impact Factor that excludes self-citation. They also suppress certain journals (do not give them an Impact Factor) or issue an expression of concern for excessive self-citation or for “citation stacking” (sometimes referred to as participating in “citation rings”), which artificially inflates the Impact Factor. 5 , 6  

This year, Clarivate introduced a new metric, the Journal Citation Indicator. 7   This new metric counts 3 yr of citations, only counts citations to citable items ( e.g. , research and reviews) but not noncitable items ( e.g. , letters, news, editorials), and normalizes journals within their field of research (thus not biasing against journals in smaller fields, and making the metric easily interpreted and more uniform across disciplines). The Journal Citation Indicator may mitigate some of the Impact Factor gaming. The Anesthesiology Journal Citation Indicator is 2.56 and is ranked no. 1 in the field.

We want Anesthesiology to be leading in scholarly content but also on issues of policy and scholarly integrity. Quality peer review remains a hallmark of Anesthesiology , in service to readers, patients, and the public trust, and we highlighted its importance and questioned the recent trend toward valuing publication speed over quality. 8   As a reminder to readers, the peer review process does not necessarily stop at publication. Readers may seek additional information; raise issues about the conduct, reporting, or interpretation of research; and offer alternative interpretations and conclusions based on available evidence by writing a letter to the editor. Article authors may reply to such letters, and the paired dialogue can be useful to readers by serving to clarify and/or amplify the message in an original article. We addressed the importance of recognizing collaborators in research and Journal mechanisms for doing so, as well as the ethics of authorship and criteria for authorship in Anesthesiology , salami publication versus appropriate use of segmented publication, and other elements of scientific integrity. 9   As research protocols become more common and authors may describe them in more than one publication, we clarified what constitutes legitimate limited text recycling so that authors can use their best description of what they had done. 8   In addition, this helps to draw a brighter line against plagiarism. Last, we reiterate the need, grounded in ethics, research validity, and sponsor requirements, for the study of both sexes in animal and human research. 10  

While we continue to face uncertainties, nonetheless we will go where the science takes us.

The author thanks Ryan Walther and Vicki Tedeschi for assistance in the preparation of this editorial.

Dr. Kharasch is the Editor-in-Chief of A nesthesiology , and his institution receives salary support from the American Society of Anesthesiologists (Schaumburg, Illinois) for this position.

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eTable. Indications for Cesarean Delivery and General Anesthesia

eFigure. Rates of General Anesthesia in Laboring Patients by Race and Ethnicity

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Thomas CL , Lange EMS , Banayan JM, et al. Racial and Ethnic Disparities in Receipt of General Anesthesia for Cesarean Delivery. JAMA Netw Open. 2024;7(1):e2350825. doi:10.1001/jamanetworkopen.2023.50825

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Racial and Ethnic Disparities in Receipt of General Anesthesia for Cesarean Delivery

• 1 Department of Anesthesiology and Critical Care, University of Chicago Medical Center, Chicago, Illinois
• 2 Department of Anesthesia, Emory University, Atlanta, Georgia
• 3 Department of Anesthesiology, Northwestern University, Chicago, Illinois
• 4 Feinberg School of Medicine, Northwestern University, Chicago, Illinois
• 5 Department of Public Health Services, University of Chicago, Chicago, Illinois
• 6 Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus
• 7 Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, Illinois
• 8 Department Obstetrics & Gynecology, University of Chicago Medical Center, Chicago, Illinois
• 9 Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida

Question   Do rates of general anesthesia use for cesarean delivery differ by race or ethnicity?

Findings   In this cross-sectional study including 35 117 patients undergoing cesarean delivery, rates of general anesthesia use were higher among Black and Hispanic individuals. However, among patients who labored with an epidural catheter in situ, there were no significant differences in rates of general anesthesia use by race or ethnicity.

Meaning   This study suggests that use of neuraxial labor analgesia may mitigate racial or ethnic disparities in general anesthesia use for cesarean delivery.

Importance   General anesthesia for cesarean delivery is associated with increased maternal morbidity, and Black and Hispanic pregnant patients have higher rates of general anesthesia use compared with their non-Hispanic White counterparts. It is unknown whether risk factors and indications for general anesthesia differ among patients of differing race and ethnicity.

Objective   To evaluate differences in general anesthesia use for cesarean delivery and the indication for the general anesthetic by race and ethnicity.

Design, Setting, and Participants   In this retrospective, cross-sectional, single-center study, electronic medical records for all 35 117 patients who underwent cesarean delivery at Northwestern Medicine’s Prentice Women’s Hospital from January 1, 2007, to March 2, 2018, were queried for maternal demographics, clinical characteristics, obstetric and anesthetic data, the indication for cesarean delivery, and the indication for general anesthesia when used. Data analysis occurred in August 2023.

Exposure   Cesarean delivery.

Main Outcomes and Measures   The rate of general anesthesia for cesarean delivery by race and ethnicity.

Results   Of the 35 117 patients (median age, 33 years [IQR, 30-36 years]) who underwent cesarean delivery, 1147 (3.3%) received general anesthesia; the rates of general anesthesia were 2.5% for Asian patients (61 of 2422), 5.0% for Black patients (194 of 3895), 3.7% for Hispanic patients (197 of 5305), 2.8% for non-Hispanic White patients (542 of 19 479), and 3.8% (153 of 4016) for all other groups (including those who declined to provide race and ethnicity information) ( P  < .001). A total of 19 933 pregnant patients (56.8%) were in labor at the time of their cesarean delivery. Of those, 16 363 (82.1%) had neuraxial labor analgesia in situ. Among those who had an epidural catheter in situ, there were no racial or ethnic differences in the rates of general anesthesia use vs neuraxial analgesia use (Asian patients, 34 of 503 [6.8%] vs 1289 of 15 860 [8.1%]; Black patients, 78 of 503 [15.5%] vs 1925 of 15 860 [12.1%]; Hispanic patients, 80 of 503 [15.9%] vs 2415 of 15 860 [15.2%]; non-Hispanic White patients, 255 of 503 [50.7%] vs 8285 of 15 860 [52.2%]; and patients of other race or ethnicity, 56 of 503 [11.1%] vs 1946 of 15 860 [12.3%]; P  = .16). Indications for cesarean delivery and for general anesthesia were not different when stratified by race and ethnicity.

Conclusions and Relevance   Racial disparities in rates of general anesthesia continue to exist; however, this study suggests that, for laboring patients who had labor epidural catheters in situ, no disparity by race or ethnicity existed. Future studies should address whether disparities in care that occur prior to neuraxial catheter placement are associated with higher rates of general anesthesia among patients from ethnic and racial minority groups.

Widespread adoption of neuraxial analgesia and anesthesia into clinical obstetric anesthesia practice has resulted in a reduction in anesthesia-related maternal morbidity and mortality in the peripartum period. 1 , 2 As rates of general anesthesia for cesarean delivery have decreased, there has been a coincident decrease in anesthesia-related morbidity and mortality. 1 , 3 , 4 Compared with neuraxial anesthesia, general anesthesia for cesarean delivery is associated with higher rates of cardiac arrest, aspiration of gastric contents, airway management complications, surgical site infections, postpartum hemorrhage, and maternal mortality. 1 , 5 - 8 Furthermore, neuraxial anesthesia techniques allow for the administration of neuraxial opioids for postoperative pain control, thus minimizing systemic opioid use and improving maternal ambulation and return of bowel function while also decreasing opioid exposure to the fetus. 5 , 9 - 11

Reasons for general anesthesia use in modern clinical practice might include rescue general anesthesia for inadequate neuraxial anesthesia, general anesthesia during emergency circumstances in which there is not time to safely provide neuraxial anesthesia, or patient refusal of neuraxial anesthesia. Reducing rates of potentially avoidable use of general anesthesia has been proposed as an actionable clinical intervention to improve maternal morbidity and outcomes. 12 Rates of preventable general anesthetics are high (up to 44%) and are associated with anesthetic complications, surgical site infections, and venous thromboembolic events.

Racial disparities exist in the rates of neuraxial labor analgesia use, as well as in the use of neuraxial anesthesia for cesarean delivery. 13 - 16 Non-Hispanic Black (hereafter, Black) and Hispanic patients have higher odds of undergoing general anesthesia for cesarean delivery compared with non-Hispanic White (hereafter, White) patients. 17 , 18 There is a paucity of literature addressing why this disparity exists, and most studies evaluating racial and ethnic disparities in anesthetic techniques for cesarean delivery have been performed on a population level, lacking granularity.

Consequently, it is uncertain whether risk factors and indications for general anesthesia for cesarean delivery differ among racial and ethnic groups. 12 , 18 Identifying and addressing the cause of racial and ethnic anesthetic disparities may improve maternal outcomes and lessen disparity gaps. The objective of this study was to evaluate differences in general anesthesia use for cesarean delivery and its indications by race and ethnicity.

The study was approved by the Northwestern University institutional review board. A waiver of consent was granted for retrospective medical record review. Electronic medical record data for all pregnant patients who underwent a cesarean delivery at Northwestern Medicine’s Prentice Women’s Hospital between January 1, 2007, and March 2, 2018, were evaluated using the Northwestern University Enterprise Data Warehouse. The start date was selected based on the date on which electronic medical record data were first available for neuraxial labor analgesia. The end date was chosen as the date the hospital migrated to a new electronic medical record system. The only exclusion criterion was perimortem cesarean delivery. This report followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline for cross-sectional studies. 19

Demographic data extracted from the medical record using an electronic medical record query included maternal age, race and ethnicity, body mass index, insurance status (private insurance, Medicaid or public insurance, or unknown insurance status or none), and maternal comorbidities including diagnoses of anemia, diabetes, and hypertensive disorders of pregnancy. Race and ethnicity information was self-identified and provided by the patient on admission. At the time of data entry, there was not an option for a multiracial or multiethnic self-identification.

Race and ethnicity were then queried from the medical record. Data were classified as Asian, Black, Hispanic, White, and other. The “other” category included data for patients with low study representation (ie, American Indian or Alaska Native and Native Hawaiian or Pacific Islander) and patients without information on race or ethnicity.

Obstetric data included parity, gestational age, indication for the cesarean delivery, and whether the patient was laboring prior to the cesarean delivery. Information regarding laboring vs nonlaboring status was obtained from nursing documentation. Information regarding postpartum hemorrhage was queried from delivery notes; postpartum hemorrhage was defined as an estimated blood loss of greater than 1 L. Data regarding maternal comorbidities, such as diabetes or anemia, were obtained from a combination of billing codes from the hospital discharge summary, nursing flowsheets, and physician documentation.

Anesthetic data included the American Society of Anesthesiologists physical status classification, including emergency designation, anesthetic technique for cesarean delivery, and the presence of existing neuraxial labor analgesia. Patients who received both neuraxial and general anesthesia were classified as having received general anesthesia. For patients who received general anesthesia, both the indication for the cesarean delivery and the indication for general anesthesia were manually extracted via medical record review and were categorized using criteria modified from prior studies (eTable in Supplement 1 ). 18 , 20

Manual extraction of the indication for cesarean delivery and the indication for general anesthesia for each patient who underwent general anesthesia was performed by 2 of us (C.L.T. and Y.Z.). Failed neuraxial anesthesia was defined as either a failed initiation of spinal anesthesia or a failed intrapartum extension of an in situ catheter, not in the setting of fetal or obstetric emergency. Neuraxial anesthesia failure could have occurred for a number of reasons (eg, inadequate dermatomal coverage prior to cesarean delivery, intraoperative discomfort necessitating conversion to general anesthesia, or inability to place a spinal or epidural catheter).

Additional data collected included neonatal outcome (live birth vs fetal demise), postpartum hemorrhage, maternal blood transfusion, maternal postoperative intensive care unit admission, and severe maternal morbidity. For severe maternal morbidity, we used a composite of 21 conditions defined by the Centers for Disease Control and Prevention. 21

The primary outcome was the rate of general anesthesia use stratified by race and ethnicity. Statistical analysis was performed in August 2023. Normal distribution of continuous variables was evaluated with the Shapiro-Wilk test. Categorical data were compared using the Pearson χ 2 test or the Fisher exact test, and continuous data were compared using the Mann-Whitney test. Univariate and multivariable mixed-effects logistic regression analyses were performed to evaluate the associations between general anesthesia use and all risk factors. Potential risk factors identified in univariate analysis with P  ≤ .10 were incorporated into a multivariable mixed-effects logistic regression model to create adjusted odds ratios (AORs) for general anesthesia use, in which the random effect was multiple deliveries by the same patient. Variables in the final multivariable mixed-effects logistic regression model included maternal age, race and ethnicity, insurance status, parity, multiple pregnancy, and preeclampsia. All P values were from 2-sided tests and results were deemed statistically significant at P  < .05. Data were analyzed using Stata/SE, version 18 (StataCorp LP).

A total of 35 117 individuals (median age, 33 years [IQR, 30-36 years]) who underwent cesarean deliveries were identified; none were excluded because of perimortem status. Of patients undergoing cesarean delivery, 2422 were Asian (6.9%), 3895 were Black (11.1%), 5305 were Hispanic (15.1%), 19 479 were White (55.5%), and 4016 (11.4%) had other racial or ethnic identities or did not provide race and ethnicity information ( Table 1 ). Patients who received general anesthesia were more likely than those who received neuraxial anesthesia to have public insurance, be parous, have multiple gestations, and carry a maternal diagnosis of gestational hypertension or preeclampsia. They also had a higher American Society of Anesthesiologists physical status classification and were more likely to be designated as requiring emergency delivery. General anesthesia was performed in 1147 of cases (3.3%). A total of 19 933 pregnant patients (56.8%) were in labor immediately prior to their cesarean delivery. The rates of general anesthesia differed by race and ethnicity and were 2.5% for Asian patients (61 of 2422), 5.0% for Black patients (194 of 3895), 3.7% for Hispanic patients (197 of 5305), 2.8% for White patients (542 of 19 479), and 3.8% for all other patients (153 of 4016) ( P  < .001).

Patients undergoing general anesthesia had higher rates of composite severe maternal morbidity, more intensive care unit admissions, higher rates of fetal demise, and higher rates of blood transfusion ( Table 2 ). After controlling for covariates, Black patients’ odds of undergoing general anesthesia were 1.42 times that of White patients (AOR, 1.42 [95% CI, 1.15-1.75]) ( Table 3 ). Other independent risk factors for general anesthesia included public insurance status (AOR, 1.31 [95% CI, 1.12-1.55]), multiple gestations (AOR, 1.47 [95% CI, 1.19-1.82]), and a diagnosis of preeclampsia (AOR, 2.61 [95% CI, 2.03-3.37]). Older age was a protective factor against general anesthesia (AOR, 0.96 [95% CI, 0.94-0.97]).

There were racial and ethnic differences between the general anesthesia rates and neuraxial anesthesia rates among patients in labor (eFigure in Supplement 1 ); however, there were no differences among the laboring patients who had an epidural catheter in situ (Asian patients, 34 of 503 [6.8%] vs 1289 of 15 860 [8.1%]; Black patients, 78 of 503 [15.5%] vs 1925 of 15 860 [12.1%]; Hispanic patients, 80 of 503 [15.9%] vs 2415 of 15 860 [15.2%]; White patients, 255 of 503 [50.7%] vs 8285 of 15 860 [52.2%]; and patients of other race or ethnicity, 56 of 503 [11.1%] vs 1946 of 15 860 [12.3%]; P  = .16) ( Table 2 ). Of laboring patients, 16 363 (82.1%) had a preexisting epidural catheter in situ at the time of cesarean delivery.

The 3 most common indications for cesarean delivery being performed with general anesthesia were obstetric or fetal emergency, arrest of labor, and maternal hemorrhage ( Table 4 ). The 3 most common indications for general anesthesia use were obstetric or fetal emergency, failed neuraxial anesthesia, and maternal contraindications to neuraxial anesthesia. Neither the indications for cesarean delivery nor the indications for general anesthesia use differed by race or ethnicity.

This study demonstrates that racial and ethnic disparities exist in the use of general anesthesia for cesarean delivery. These findings are consistent with other studies showing that Black patients are nearly twice as likely to undergo general anesthesia for cesarean delivery as White patients. 17 , 18 This study extends those findings by demonstrating that there is no racial or ethnic disparity when labor epidural analgesia is provided prior to intrapartum cesarean delivery. The reduction of racial and ethnic disparities among patients with neuraxial catheters in situ for labor is a novel and clinically important finding, as the presence of a catheter in situ for labor allows for the ability to convert labor analgesia to surgical anesthesia for cesarean delivery. In the event that an urgent or intrapartum cesarean delivery is required, timely conversion of neuraxial labor analgesia to anesthesia is one strategy for avoiding a preventable general anesthetic. 22 , 23

Disparities do exist in neuraxial labor analgesia use, and Black and Hispanic patients are less likely than White patients to receive neuraxial analgesia. 15 , 24 , 25 Black individuals are less likely to have private insurance and more likely to have no insurance compared with White individuals, 25 and insurance coverage is associated with significant improvements in access to care, condition-specific outcomes, and self-reported health. 26 - 28 It is likely that a combination of systemic factors, social determinants of health, clinician factors such as implicit and/or explicit bias, and communication barriers are associated with the disparity in rates of neuraxial analgesia use. 29 , 30

While the optimal rate of general anesthesia for cesarean delivery is unknown, national societies such as the Society for Obstetric Anesthesia and Perinatology have established benchmarks and recommendations, with a proposed goal of less than 5% of cesarean deliveries being performed under general anesthesia. 31 Given that neuraxial labor analgesia may act as a safety mechanism to prevent use of general anesthesia, it is imperative that disparities in neuraxial labor analgesia use be further investigated and addressed. It is possible that early explanation of labor analgesic options and identification of patient preferences in regard to neuraxial analgesia may be key to mitigating disparities in neuraxial labor anesthesia care. 32 , 33 In addition, because having an epidural in situ for an intrapartum cesarean delivery was associated with a similar general anesthesia rate stratified by race and ethnicity, future studies may consider evaluating intrapartum vs nonintrapartum cesarean deliveries for obstetrical indications. Nonintrapartum cesarean deliveries might have other actionable factors that should be examined with a health care equity lens.

Given that we manually reviewed each case of an individual receiving general anesthesia, we are able to provide granular data about the clinical indication for the cesarean delivery and general anesthesia. These types of data are challenging to obtain from large databases that rely on administrative data or registries. We found no significant disparities in indications for cesarean delivery performed under general anesthesia or in the indications for general anesthesia.

Our study has some limitations. Due to the single-center nature of the data, the results may not be generalizable to maternal care in the US. The labor analgesia use rate at Northwestern Medicine’s Prentice Women’s Hospital is, on average, above 95%, indicating that the risk of avoidable general anesthesia for our patient cohort may be lower than other institutions where labor analgesia is used less often. 12 In addition, our data are retrospective; thus, we cannot infer causality. Our data lacked information that could categorize the urgency of cesarean delivery, which precluded our ability to evaluate general anesthetics for preventability. Because this study investigates only patients who underwent cesarean delivery, we are unable to provide rates of labor analgesia by race and ethnicity for all laboring patients at our institution.

These findings have both clinical and public health implications. The data suggest that the racial and ethnic disparities in general anesthesia rates exist in association with neuraxial catheter placement and that once a neuraxial catheter is in situ, these disparities no longer existed for the subset of patients undergoing intrapartum cesarean delivery. We speculate that the cause of this finding may be complex and may involve both patient-related and clinician-related factors. Future studies are needed to further elucidate the cause of the discrepancy in the administration of general anesthesia and neuraxial analgesia and strategies to eliminate it. Attention should focus on patient-centered, timely administration of neuraxial labor analgesia and on identifying actionable items among patients without epidural labor analgesia. In addition, future studies should attempt to replicate our findings to improve generalizability. These findings underscore the need to identify modifiable risk factors for general anesthesia use, to mitigate risk.

Accepted for Publication: November 19, 2023.

Published: January 9, 2024. doi:10.1001/jamanetworkopen.2023.50825

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Thomas CL et al. JAMA Network Open .

Corresponding Author: Caroline Leigh Thomas, MD, Department of Anesthesiology and Critical Care, University of Chicago Medical Center, 5841 S Maryland Ave, Room I-440, MC4028, Chicago, IL 60637 ( [email protected] ).

Author Contributions: Dr Thomas had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Thomas, Lange, Banayan, Peralta, Scavone, Toledo.

Acquisition, analysis, or interpretation of data: Thomas, Banayan, Zhu, Liao, Grobman, Scavone, Toledo.

Drafting of the manuscript: Thomas, Peralta, Toledo.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Liao, Toledo.

Obtained funding: Toledo.

Administrative, technical, or material support: Thomas, Zhu, Toledo.

Supervision: Lange, Grobman, Scavone, Toledo.

Conflict of Interest Disclosures: Dr Toledo reported receiving speaker’s fees from Pacira BioSciences Inc outside the submitted work. No other disclosures were reported.

Funding/Support: Dr Toledo has received funding from the National Institute on Minority Health and Health Disparities (grant R03MD011628), the Anesthesia Patient Safety Foundation, and the Shane Foundation.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Minority Health and Health Disparities, the Anesthesia Patient Safety Foundation, or the Shane Foundation.

Data Sharing Statement: See Supplement 2 .

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Stanford health care – now.

Louise Sun, MD, MS

“The aging population is bringing increasingly complex comorbidities to what are already incredibly complicated operations,” explains Louise Sun, MD, MS, chief of the Division of Cardiovascular and Thoracic Anesthesia at Stanford University School of Medicine. As part of their role, cardiothoracic anesthesiologists perform extensive preoperative evaluations to understand patient characteristics in order to optimize the care that they receive. This also includes providing postoperative intensive care in the cardiovascular intensive care unit (CVICU).

“We synthesize all of the information presented by each patient into a personalized plan that maximizes the success of the surgical team before, during, and after the operation,” she says.

Capitalizing on big data to improve healthcare delivery Prior to her arrival at Stanford Health Care, Dr. Sun was a clinician research chair and Director of Bioinformatics Research at the University of Ottawa Heart Institute at the University of Ottawa, Ontario, Canada. These roles, along with cross-appointment as a faculty member at the Institute for Clinical and Evaluative Sciences (ICES), offered unique opportunities for big data and population health research. They also capitalized on her epidemiology and bioengineering background, as well as experience with informatics and computational approaches.

Dr. Sun’s population-based studies using ICES data offered novel perspectives on cardiac surgery and readmission rates, as well as the impact of sex differences on heart failure, access to care, and patient outcomes. 1-5 “I’m particularly passionate about finding ways to use the enormous volumes of medical information generated by health systems to develop predictive models capable of optimizing care delivery and efficiency,” Dr. Sun explains.

This process requires the clinical experience necessary to understand and identify the value of the raw data. Clinicians also need to determine how to effectively transform that data into something meaningful. In this regard, Dr. Sun acknowledges that having multiple skill sets helps her identify clinically relevant problems and quickly develop potential solutions.

“I’m fortunate that my clinical experience affords a degree of credibility for the models that we develop, which tends to streamline their entry into the clinical workflow,” she says. “An ability to explain how and why these models work also lends transparency to the process and allows a broader understanding of their benefit to both patients and clinicians.”

Predictive modeling to optimize patient outcomes During the early COVID-19 pandemic, Dr. Sun began a study to address overcrowded ICUs. This research later expanded to address unnecessary CVICU occupancy resulting from extended lengths of stay (LOS) in the hospital following cardiac surgery. Prolonged LOS resulted in large patient waitlists for elective cardiac surgery procedures, with some of those patients ultimately dying or requiring hospitalization while on the list.

The large size and scope of the ICES data help create models that can demonstrate predictive accuracy across diverse patient populations. Using these data, Dr. Sun and her colleagues developed a set of new clinical risk score models. These models could support triage by more efficiently prioritizing patients according to their symptoms and medical profiles. Dr. Sun’s team showed that using this model could potentially streamline procedure scheduling, decrease health-related deterioration on the waitlist, and maximize the availability of both CVICU beds and clinical staff. 3,6-8

“My daily interactions with patients and staff provided the context necessary to understand which variables in the data would contribute most to the accuracy of the predictive model,” Dr. Sun explains. Although developed using data from Canada, the concept also has immediate applicability to stateside hospitals. “We’re currently attempting to validate these models at Stanford Health Care in order to address similar capacity challenges in the emergency department and CVICU.”

Using biomarkers to identify heart failure risk Another active area of Dr. Sun’s research involves designating patients at high risk of right ventricular failure (RVF) following cardiac surgery. RVF can have devastating consequences in terms of postsurgery mortality and morbidity. Dr. Sun’s team identified biomarkers demonstrating both sensitivity and specificity for predicting RVF across different patient populations. 9

“We found that changes in these biomarkers before, during, and after surgery offer reliable insight into a patient’s risk profile,” Dr. Sun explains. Observing certain biomarker levels at baseline can also help predict postsurgery RVF risk. “Because prevention is the best treatment in these cases, early identification of a potential problem allows us to intervene appropriately, with the goal of avoiding adverse events during and after the procedure.” Dr. Sun’s multidisciplinary team also published standardized definitions for RVF in the context of cardiac surgery to provide a uniform standard to evaluate clinical practice and conduct research studies. 10

Enabling data-driven management of intraoperative blood pressure Hypotension occurs in up to 99% of surgeries and is among the few modifiable risk factors for major operative morbidity and mortality. Dr. Sun’s team leveraged informatics techniques to identify critical thresholds and durations of intraoperative hypotension related to the development of important postoperative complications following cardiac and noncardiac surgery.

Their findings supported a personalized approach to defining blood pressure thresholds according to baseline risk factors presented by each individual patient. Importantly, the results showed that postsurgical risks, including death, stroke, acute kidney injury, and the need for renal replacement therapy, could be modified by precisely managing intraoperative blood pressure. 11-15    

Her research has enabled her to make wide-reaching contributions to perioperative safety.

As a member of the Anesthesia Patient Safety Foundation expert consensus group, Dr. Sun recently provided recommendations on the management of perioperative hemodynamic instability. 16 Her team’s efforts have also led to patented, AI-driven technology supporting the prediction and prevention of hypotension in the operating room and ICU.

Driving emerging leaders and gender equity in cardiothoracic anesthesiology Dr. Sun acknowledges Stanford Medicine’s track record of innovation and research excellence as a major motivation in her decision to move. She emphasizes that this position offered an unprecedented opportunity to mentor the next generation of leaders in the field. These include faculty engaged in paradigm-shifting research:        

• Kristen Rhee Steffner, MD , is developing deep learning-based approaches to evaluating and classifying transesophageal echocardiography images obtained during cardiac surgery. 17
• Albert H. Tsai, MD , is evaluating the use of augmented reality as a medical simulation modality for applications in cardiovascular anesthesiology training. 18
• Vikram Fielding-Singh, MD , is using population-based repositories to evaluate the outcomes of patients with pre-existing renal dysfunction. 19

As one of the few female division chiefs of cardiothoracic anesthesiology in the nation, Dr. Sun notes that the high proportion of women in the division (55%) marks it as one of the most gender-balanced program of its kind in the nation. Yet as of 2021, only 26.1% of anesthesiologists in the United States are female. 20

The lack of female anesthesiologists nationwide has a significant impact on patient welfare. Decades of research offer evidence that physician-patient sex discordance can adversely affect patient surgical outcomes, particularly when the patient is female. 21 Dr. Sun’s research has also demonstrated how surgeon-anesthesiologist sex discordance (mixed-sex teams) can improve outcomes in cardiac and noncardiac surgery settings. 22

“The gender equity in our division is certainly a point of emphasis during the recruitment of faculty and fellowship candidates,” explains Dr. Sun. “Because we operate in a setting where effective communication is a matter of life and death, fostering a culture of openness and inclusion is essential to delivering the best care possible.”  

Learn more about the Division of Cardiovascular and Thoracic Anesthesia and the spectrum of care offered by Stanford Health Care.

References:

• Sun LY, Chu A, Tam DY, et al. Derivation and validation of predictive indices for cardiac readmission after coronary and valvular surgery - A multicenter study. Am Heart J Plus . 2023;28:100285. https://pubmed.ncbi.nlm.nih.gov/38511073/
• Rubens FD, Clarke AE, Lee DS, Wells GA, Sun LY. Population study of sex-based outcomes after surgical aortic valve replacement. CJC Open . 2022;5(3):220-229.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10066438/
• Sun LY, Wijeysundera HC, Lee DS, et al. Derivation and validation of a clinical risk score to predict death among patients awaiting cardiac surgery in Ontario, Canada: A population-based study. CMAJ Open . 2022;10(1):E173-E182. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9259465/
• Sun LY, Zghebi SS, Eddeen AB, et al. Derivation and external validation of a clinical model to predict heart failure onset in patients with incident diabetes. Diabetes Care . 2022;45(11):2737-2745. https://pubmed.ncbi.nlm.nih.gov/36107673/
• Sun LY, Tu JV, Coutinho T, et al. Sex differences in outcomes of heart failure in an ambulatory, population-based cohort from 2009 to 2013. CMAJ . 2018;190(28):E848-E854. https://pubmed.ncbi.nlm.nih.gov/30012800/
• Sun LY, Eddeen AB, Wijeysundera HC, Mamas MA, Tam DY, Mesana TG. Derivation and validation of a clinical model to predict death or cardiac hospitalizations while on the cardiac surgery waitlist. CMAJ . 2021;193(34):E1333-E1340. https://pubmed.ncbi.nlm.nih.gov/34462293/
• Fottinger A, Eddeen AB, Lee DS, Woodward G, Sun LY. Derivation and validation of pragmatic clinical models to predict hospital length of stay after cardiac surgery in Ontario, Canada: a population-based cohort study. CMAJ Open . 2023;11(1):E180-E190. https://pubmed.ncbi.nlm.nih.gov/36854454/
• Sun LY, Bader Eddeen A, Ruel M, MacPhee E, Mesana TG. Derivation and validation of a clinical model to predict intensive care unit length of stay after cardiac surgery. J Am Heart Assoc . 2020;9(21):e017847. https://pubmed.ncbi.nlm.nih.gov/32990156/
• MacMillan YS, Mamas MA, Sun LY. IGFBP7 as a preoperative predictor of congestive acute kidney injury after cardiac surgery. Open Heart . 2022;9(1):e002027. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9226986/
• Jabagi H, Nantsios A, Ruel M, Mielniczuk LM, Denault AY, Sun LY. A standardized definition for right ventricular failure in cardiac surgery patients. ESC Heart Fail . 2022;9(3):1542-1552. https://pubmed.ncbi.nlm.nih.gov/35266332/
• Sun LY, Chung AM, Farkouh ME, et al. Defining an intraoperative hypotension threshold in association with stroke in cardiac surgery. Anesthesiology . 2018;129(3):440-447. https://pubmed.ncbi.nlm.nih.gov/29889106/
• Sun LY, Wijeysundera DN, Tait GA, Beattie WS. Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery. Anesthesiology. 2015;123(3):515-523. https://pubmed.ncbi.nlm.nih.gov/26181335/
• Ngu JMC, Jabagi H, Chung AM, et al. Defining an intraoperative hypotension threshold in association with de novo renal replacement therapy after cardiac surgery. Anesthesiology. 2020;132(6):1447-1457. https://pubmed.ncbi.nlm.nih.gov/32205546/
• Sun LY. Preoperative risk, blood pressure, and acute kidney injury. Anesthesiology. 2020;132(3):416-417. https://pubmed.ncbi.nlm.nih.gov/31929330/
• Ristovic V, de Roock S, Mesana TG, van Diepen S, Sun LY. The impact of preoperative risk on the association between hypotension and mortality after cardiac surgery: An observational study. J Clin Med . 2020;9(7):2057. https://pubmed.ncbi.nlm.nih.gov/32629948/
• Scott MJ; APSF Hemodynamic Instability Writing Group. Perioperative patients with hemodynamic instability: Consensus recommendations of the Anesthesia Patient Safety Foundation. Anesth Analg . 2024;138(4):713-724. https://pubmed.ncbi.nlm.nih.gov/38153876/
• Steffner KR, Christensen M, Gill G, et al. Deep learning for transesophageal echocardiography view classification. Sci Rep . 2024;14(1):11. https://pubmed.ncbi.nlm.nih.gov/38167849/
• Tsai A, Bodmer N, Hong T, et al. Participant perceptions of augmented reality simulation for cardiac anesthesiology training: A prospective, mixed-methods study. J Educ Perioper Med . 2023;25(3):E712. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10502607/
• Fielding-Singh V, Vanneman MW, Lin E. Preoperative hemodialysis timing and postoperative mortality in patients with end-stage kidney disease-reply. JAMA . 2023;329(11):939-940. https://pubmed.ncbi.nlm.nih.gov/36943217/
• Active Physicians by Sex and Specialty, 2021. Association of American Medical Colleges; 2021. https://www.aamc.org/data-reports/workforce/data/active-physicians-sex-specialty-2021
• Wallis, CJD, Jerath, A, Coburn N, et al. Association of surgeon-patient sex concordance with postoperative outcomes. JAMA Surg . 2022;157(2):146-156. https://jamanetwork.com/journals/jamasurgery/fullarticle/2786671
• Etherington C, Boet S, Chen I, et al. Association between surgeon/anesthesiologist sex discordance and 1-year mortality among adults undergoing noncardiac surgery: A population-based retrospective cohort study. Ann Surg . 2024;279(4):563-568. https://pubmed.ncbi.nlm.nih.gov/37791498/

About Stanford Health Care

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Recent advances in the technology of anesthesia

Christian seger.

1 Department of Anesthesiology and Perioperative Medicine,UCLA David Geffen School of Medicine, University of California, 757 Westwood Plaza, Los Angeles, CA, 90095, USA

Maxime Cannesson

The practice of anesthesiology is inextricably dependent upon technology. Anesthetics were first made possible, then increasingly safe, and now more scalable and efficient in part due to advances in monitoring and delivery technology. Herein, we discuss salient advances of the last three years in the technology of anesthesiology.

Consumer technology and telemedicine have exploded onto the scene of outpatient medicine, and perioperative management is no exception. Preoperative evaluations have been done via teleconference, and copious consumer-generated health data is available. Regulators have acknowledged the vast potential found in the transfer of consumer technology to medical practice, but issues of privacy, data ownership/security, and validity remain.

Inside the operating suite, monitoring has become less invasive, and clinical decision support systems are common. These technologies are susceptible to the “garbage in, garbage out” conundrum plaguing artificial intelligence, but they will improve as network latency decreases. Automation looms large in the future of anesthesiology as closed-loop anesthesia delivery systems are being tested in combination (moving toward a comprehensive system).

Moving forward, consumer health companies will search for applications of their technology, and loosely regulated health markets will see earlier adoption of next-generation technology. Innovations coming to anesthesia will need to account for human factors as the anesthesia provider is increasingly considered a component of the patient care apparatus.

Introduction

The modern practice of anesthesiology is inextricably dependent upon technology. This dependence is not as strong among the other medical specialties and makes a review of recent advances particularly germane to the determination of our field’s future. Technology first made anesthesia possible, then safe, and will seek to make it increasingly scalable and efficient in health-care systems pressed for resources both economic and human 1 . Herein, we discuss salient advances occurring over the last three years, focusing on automation, monitoring, and decision support systems. We lastly begin a discussion of innovation landscape in anesthesiology during the 21st century.

Automation in the delivery of anesthetics

Equipment used to perform any task, even complicated tasks like providing an anesthetic, can be described along a spectrum from tooling to automation. A tool is powered directly by its user, whereas a machine augments its user’s input via some external power source but remains directly under user control. The hallmark of automation is the ability of a machine to alter its function without direct user input but in pursuit of a user-defined objective. Anesthesiologists used mostly tools and machines at the end of the 20th century. As the 21st century dawns, automated anesthetics become increasingly prevalent. The closed-loop anesthesia delivery system (CLADS) relies on a completed or “closed” feedback loop. Briefly, an automated device (for example, a ventilator) must be trained to a goal (for example, end-tidal carbon dioxide (CO 2 ) level) and govern an input that affects that goal (for example, minute ventilation). The causal interdependence of these factors is the “closed loop”. The common cruise control found in most automobiles is a simple closed-loop system receiving speed as its input and adjusting engine power to achieve a driver-set speed target. As when a car is being driven with the cruise control disengaged, the intraoperative warrant of an anesthetic provider is to make decisions based on data (for example, end-tidal CO 2 ) and implement changes (for example, alter minute ventilation via the ventilator). In the US, no truly automated CLADS is approved for commercial clinical use. Still, anesthetic workstations, infusion pumps, and monitors have progressed as increasingly intricate machines that ultimately leave the feedback loop “open” for the anesthesia provider to close themselves. Outside the US, automated CLADSs are employed in research and increasingly in clinical practice 2 . These systems were first developed separately for specific parameters (for example, processed electroencephalogram (EEG) monitoring, hemodynamic goals, and fluid resuscitation) and have been assessed in specific clinical scenarios, including in patient populations with relatively high comorbidity (cardiac surgery 3 and transcatheter aortic valve implantation 4 ). In broader populations, the safety of these systems has been reviewed extensively 5 , 6 . Automated anesthetic systems incorporating independent closed-loops for hypnosis, analgesia, and fluid management are undergoing feasibility studies 7 . In one multicenter randomized controlled trial of parallel CLADSs using propofol and fentanyl, targeted to the proprietary bispectral index (BIS) and heart rate, the CLADS maintained significantly tighter control than manual operation over BIS ( P <0.0001) and heart rate within 25% of baseline ( P <0.0031) 8 . Inter-center variation among these parameters was minimal with automation ( P = 0.94) and significant with manual control ( P <0.001) 8 . CLADS controlled total intravenous anesthetic (TIVA) infusions have also been shown to more tightly regulate depth of anesthesia, shorten recovery time, and reduce sedative agent consumption when compared with standard practice in a meta-analysis 9 . Neurocognitive recovery, a measure of clinical importance beyond the perioperative period, might also be improved under automated TIVA administration 10 . Pediatric applications are also developing 11 . The February 2020 issue of Anesthesiology featured an editorial“Robots will Perform Anesthesia in the Near Future” 12 . In some markets, automatic administration of volatile anesthetics via closed-loop titration is commercially available. We expect automation to increase rapidly, becoming the norm in the operating room in the next 10 years.

Monitoring inside the operating rooms: advances in non-invasive monitoring

Closed-loop automation requires a reliable source of data upon which to make “decisions”. For example, programming a hypothetical capnography-linked ventilator as noted above is a straightforward task governed by well-characterized physiologic principles of CO 2 production and minute ventilation. These relationships degrade significantly in the presence of data artifact: intraoperative events (for example, pulmonary embolism or myocardial infarction), endotracheal tube malposition, patient temperature, and occluded or disconnected circuit tubing all introduce variations to the capnogram signal and require intervention outside modulation of minute ventilation. Toward this end, the reliable acquisition of high-resolution, reproducible, and timely intraoperative data is foundational to any attempt at automation.

With innovation, monitoring has become less invasive. Cardiac output monitoring, which first required invasive catheters and the use of thermodilution, has been commercially available via analysis of the peripheral arterial pressure waveform for some years. More recently, truly non-invasive assessment of cardiac output became available by using a blood pressure cuff applied to the finger, such as in the CNAP system (CNSystems Medizintechnik GmbH, Graz, Austria) or the ClearSight system (Edwards Lifesciences, Irvine, CA, USA). Cerebral pulse oximetry has similarly unlocked valuable data with the potential for meaningful clinical impact, including brain autoregulation assessment 13 , 14 .

New monitoring technology is not the only means of advanced non-invasive data-gathering. Clinical information sometimes can be derived from established monitors via further in-depth analysis of the data already provided. As with the measurement of cardiac output via pulse-wave contour analysis of the radial arterial line or the treasure trove of data that can be extracted from the electrocardiogram (merely a plot of voltage varying with time), data derived from existing monitors of pulse oximetry, continuous end-tidal CO 2 , arterial pressure hold potentially valuable information to derive hemodynamic variables 15 . The analgesia nociception index, surgical pleth index, and nociception level index (NoL) are examples 16 , 17 . Edry et al . demonstrated a proportional reflection of incisional pain using the NoL, a “nonlinear combination of heart rate, heart rate variability, photoplethysmograph wave amplitude, skin conductance, skin conductance fluctuations, and their time derivatives” 17 . Because processed metrics like this naturally carry limitations 18 that limit their clinical uses (one may expect NoL scores in healthy patients to differ from those with chronic pain), understanding these limitations is prerequisite to their judicious use in closed-loop systems (for example, NoL-guided analgesic administration).

Monitoring beyond the operating room: telemedicine and wearable health-care technologies

The pursuit of new and more valuable patient data extends beyond the intraoperative setting. Consumer technology companies have poured resources into the developing consumer health-care market. The Consumer Electronics Show (CES), the preeminent trade show in the US for all things tech, now sees regular entries from consumer health-care technology seeking clinical application. Augmented reality technology from the video-gaming industry, for example, has made its way into the intensive care unit (ICU) to quantify patient mobility 19 . Wireless technologies with low latency and ever-improving stability, developed for the consumer, may someday untangle anesthesiology workstations 20 .

Telemedicine, a natural by-product of advanced videoconference products in the consumer space, and its application to the perioperative surgical home model of care constitute perhaps the clearest current example of consumer technology revolutionizing anesthesia practice. Small high-resolution cameras, microphones, and broadband data connections necessary for telemedicine have their origins in commerce and espionage. Their use in preoperative examinations, remote ICU care, intraoperative monitoring, and postoperative assessments is reviewed in detail elsewhere 21 . Data security in consumer health-care technology remains a challenge 22 , but potential financial savings and sustained patient satisfaction continue to drive the expansion of telemedicine.

Clinical decision support and anesthesia information management systems

Documentation is a necessary component of the anesthesia provider’s work. Previously, information like vital signs, fluid status, and degree of sedation flowed from the patient to the provider by way of direct observation or through monitors or the anesthesia workstation. Documentation was a one-way act of scribing data for potential review at a later time. Now, the electronic medical record and anesthesia information management systems (AIMS) act as hubs for information gathered by the provider, monitors, and anesthesia workstation. With the anesthetic record becoming a comprehensive repository of real-time patient information, the possibility of clinical decision support (CDS) systems became reality. An extensive review and future perspective on CDS and AIMS have been undertaken elsewhere 23 , 24 . Notably, CDS differs from closed-loop or automated systems in that the CDS provides notification or evidence of best practice in a variety of clinical situations but is not capable of intervention. The anesthesia provider therefore remains indispensable as the source of clinical judgment and intervention.

The fundamental challenges of artificial intelligence (AI) and behavioral science remain as obstacles to an effective CDS implementation. First, an algorithm’s output quality is dramatically altered by the quality of its input (the “garbage in, garbage out” conundrum). Quality patient data and the ability to screen for artifact are vital properties of an effective CDS. Second, CDSs provide various notifications and warnings that rely on the attention of a human provider. Thus, a CDS leaves the feedback loop of clinical care “open”. With alarm fatigue and documentation requirements mounting, there is a sizeable challenge in creating a useful and accurate CDS without it becoming burdensome in practice. Third, an effective CDS requires the processing of gargantuan mounds of clinical data in near real-time. The practicality of housing this processing power locally on an anesthesia workstation remains to be seen, but we suspect that a central processing model similar to that used by web service providers will shift this demand to low-latency networking, enabling greater portability and lower cost of the peri-procedural equipment. This will place demands on the networking and processing capacity already implemented in most practice environments. We expect the advent of consumer-grade low-latency networking (for example, 5G cellular network) to lessen this barrier significantly.

Even as connective and data processing continue to intensify, practices in security and property rights over health-care data will continue to evolve. The human data we create and gather during the 21st century will be unfathomable in scale, scope, and impact. Finding meaning in the data remains a fundamental challenge of our technological age.

The innovation landscape in anesthesiology technology

The triple aim of health care was launched in 2008 25 and has since guided many efforts in health-care development. While chasing improved outcomes at a lower cost for more patients, technology enjoys several advantages over the traditional pipeline of medical innovation.

Bottom-up innovation and so-called “solution shopping” are common: technology often makes a task or measurement possible before its clinical use, or even its clinical need, is clear. Famously, smart watches and fitness trackers introduced essentially continuous activity and heart rate monitoring, earning applause from society at large and market success. Less developed health-care systems may embrace this technology before advanced systems with pre-existing viable alternatives, leading to a “leapfrog” effect wherein nascent technology proves its validity in developing systems before adoption in advanced health-care settings. Today, clinicians in advanced health-care delivery systems remain faced with uncertain accuracy and reliability of consumer-grade medical information and have yet to codify its use in clinical care.

The fields of psychology, economics, and behavioral science will guide the implementation of the ever-increasing quantities of available patient information. Accounting for human factors and social engineering preserves the anesthesia provider’s most valuable resources: time and attention 24 . Automated systems must be paired with an understanding of human operator behavior if they are truly going to improve care. Even if implemented with the strongest multi-disciplinary evidence supporting a technology’s utility, use will vary as the discrepancy between evidence and practice continues.

Development costs and regulation persist as necessary barriers to innovation. Development costs for novel technology continue to climb in step with the intricacy of products proposed and must be counteracted in the price of implementation. Regulation continues to function as a basic quality-control measure at the societal level. Markets employ varying standards for the evidence behind new medical technology, but new regulatory pathways aimed at bridging the gap between medical and consumer technology may smooth this process. The US Food and Drug Administration has acknowledged the value of technology transfer between medical and consumer realms, most recently by presenting “Demystifying Regulation” at the CES in January 2020 in an attempt to aid tech startups navigating a complex regulatory framework.

Although some impedance to innovation can be found in prudent quality assurance, philosophical opposition to change is a human habit borne out over centuries with real impact. Technological advance in anesthesiology is an uneasy topic for many practitioners. With innovations like those we have discussed, practitioners can perceive a threat to their purpose and professional identity, perhaps even the reasons for which they dedicated their careers to the service of humanity. Institutions with a vested interest in the status quo (manufacturers, training institutions, and providers) often perceive a threat to power, influence, or prosperity in the face of sweeping change. In his last book, Innovation and its Enemies , the late director of the Harvard Kennedy School’s Science Technology and Globalization Project, Calestous Juma, details examples of this preservation instinct combatting waves of technology that upended certain sectors of society. Coffee was banned centuries ago as a substance that encouraged communal gathering and the exchange of ideas. Margarine, a threat to butter sales, was legally required to be dyed a painfully bright shade of pink. Resistance to innovation sometimes leverages coercive force (for example, law) to preserve a way of life, work, or thought. Still, today the café is ubiquitous and selling yellow margarine is not a crime. Anesthesiology’s experience with automation is already complex and under way. We suggest that embracing this wave and responsibly ushering it forward constitute the best way to avoid our own pink margarine legacy.

Conclusions

As William Gibson famously began to note in the mid 1990’s 26 , “The future is already here – It’s just not very evenly distributed”. The delivery of anesthesia, its preoperative assessments, and postoperative care vary by health system, resource setting, and society. However, the trends toward automation, non-invasive monitoring, remote monitoring and management, and CDS enabled by AI and improved information technology infrastructure are clear in our field. Each health system, in its setting, will continue to pursue improved outcomes for more patients while expending fewer resources in accordance with the triple aim. Inter-system variation will lead to leapfrog innovation where a set of advances more quickly enacted in one setting will provide the experience used to justify their implementation elsewhere.

Specifically, the CLADS is a mature technology that provides tight control of measurable variables during an anesthetic, but further study is necessary to elucidate clinical relevance (neurocognitive dysfunction aside). Monitoring has become increasingly non-invasive and processing-dependent as we extract novel metrics from proprietary combinations of existing metrics. Telemedicine has the potential to revolutionize the perioperative surgical home model of care and serves as a vanguard for the adoption of consumer-grade technology (telecommunication or otherwise) by medical fields.

Along with technological innovation, social engineering and the constructs of efficient business will help increase quality and value in anesthesia care. Increasingly intricate synthesis of the incredible quantity and breadth of health system and patient metrics will inform this process. Behavioral science and economics will additionally guide the implementation of CDS systems, underpinned by the technologies noted above, with the aims of mitigating provider fatigue and minimizing errors.

Innovation in anesthesiology continues to be driven by the triple aim of health care for the benefit of patients and society. Our approach to innovation as providers and innovators will determine our standing after these developments change our field. We believe that parts of the trends discussed above are inevitable results of economic and social forces acting upon the medical field. We also believe that an informed and alert profession can shape the coming age and guide its members to meaningful and impactful practice. The future is here, and our engagement with innovation will determine our share of its prosperity.

[version 1; peer review: 2 approved]

Funding Statement

This work is supported by National Institutes of Health (NIH) R01 HL144692 grant.

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Editorial Note on the Review Process

F1000 Faculty Reviews are commissioned from members of the prestigious F1000 Faculty and are edited as a service to readers. In order to make these reviews as comprehensive and accessible as possible, the referees provide input before publication and only the final, revised version is published. The referees who approved the final version are listed with their names and affiliations but without their reports on earlier versions (any comments will already have been addressed in the published version).

The referees who approved this article are:

• Jan F. A. Hendrickx , Department of Anesthesiology, Intensive Care and Pain Therapy, Onze Lieve Vrouw Hospital, Aalst, 9300, Belgium; Dept. of Anesthesiology, Fundamental and Applied Medical Sciences, Ghent University, Ghent, Belgium No competing interests were disclosed.
• Thomas M. Hemmerling , Department of Anaesthesia, McGill University, Montreal, Canada No competing interests were disclosed.

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Introduction: This is a literature review on pediatric anesthesiology practice from 2010 to 2020 in two reference teaching hospitals of Cotonou: National University Hospital Centre (CNHU), and Lagoon--Mother and Child Hospital Centre (CHUMEL). Objective: To highlight the advances in pediatric anesthesia in Benin through the work carried out in 2010 and those of 2020 in the two reference hospitals in southern Benin. Patients and Methods: Data concerning the sociodemographic profile of patients, epidemiologic profile, human resources, infrastructures, equipment, medications and caregiving are examined. In this study, the work carried out in 2010 was compared to those in 2020. Results: The study carried out in 2010 included 512 children under 15 years, for a year’s duration; when in 2020, 345 children were included, all of which had surgery in a five months period. Equipment and Human ressources had improved with the creation of a pediatric critical care unit. The new monitoring material, anesthetic medications, and regional anesthesia technics were not practiced in 2010. Conclusion: This work shows that the practice of pediatric anesthesia in 2020 in the two reference hospitals in Benin, compared to previous years, is becoming increasingly satisfactory, even if anesthesia safety is not yet optimal.

Pediatric Anesthesiology, Evolution, CHU-MEL

Akodjenou Joseph, Ahounou Ernest, Lalèyè Yasmine, Zoumenou Eugène, Gbénou Séraphin Antoine, et al. (2023). Pediatric Anesthesiology Practice Evolution in Benin, from the Study Research Realized in 2010 and 2020. International Journal of Anesthesia and Clinical Medicine , 11 (2), 66-68. https://doi.org/10.11648/j.ijacm.20231102.12

Akodjenou Joseph; Ahounou Ernest; Lalèyè Yasmine; Zoumenou Eugène; Gbénou Séraphin Antoine, et al. Pediatric Anesthesiology Practice Evolution in Benin, from the Study Research Realized in 2010 and 2020. Int. J. Anesth. Clin. Med. 2023 , 11 (2), 66-68. doi: 10.11648/j.ijacm.20231102.12

Akodjenou Joseph, Ahounou Ernest, Lalèyè Yasmine, Zoumenou Eugène, Gbénou Séraphin Antoine, et al. Pediatric Anesthesiology Practice Evolution in Benin, from the Study Research Realized in 2010 and 2020. Int J Anesth Clin Med . 2023;11(2):66-68. doi: 10.11648/j.ijacm.20231102.12

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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).

Disclosures

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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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

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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Received : 08 February 2022

Revised : 05 August 2022

Accepted : 06 August 2022

Published : 23 November 2022

Issue Date : February 2023

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

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Guest Essay

The Long-Overlooked Molecule That Will Define a Generation of Science

By Thomas Cech

Dr. Cech is a biochemist and the author of the forthcoming book “The Catalyst: RNA and the Quest to Unlock Life’s Deepest Secrets,” from which this essay is adapted.

From E=mc² to splitting the atom to the invention of the transistor, the first half of the 20th century was dominated by breakthroughs in physics.

Then, in the early 1950s, biology began to nudge physics out of the scientific spotlight — and when I say “biology,” what I really mean is DNA. The momentous discovery of the DNA double helix in 1953 more or less ushered in a new era in science that culminated in the Human Genome Project, completed in 2003, which decoded all of our DNA into a biological blueprint of humankind.

DNA has received an immense amount of attention. And while the double helix was certainly groundbreaking in its time, the current generation of scientific history will be defined by a different (and, until recently, lesser-known) molecule — one that I believe will play an even bigger role in furthering our understanding of human life: RNA.

You may remember learning about RNA (ribonucleic acid) back in your high school biology class as the messenger that carries information stored in DNA to instruct the formation of proteins. Such messenger RNA, mRNA for short, recently entered the mainstream conversation thanks to the role they played in the Covid-19 vaccines. But RNA is much more than a messenger, as critical as that function may be.

Other types of RNA, called “noncoding” RNAs, are a tiny biological powerhouse that can help to treat and cure deadly diseases, unlock the potential of the human genome and solve one of the most enduring mysteries of science: explaining the origins of all life on our planet.

Though it is a linchpin of every living thing on Earth, RNA was misunderstood and underappreciated for decades — often dismissed as nothing more than a biochemical backup singer, slaving away in obscurity in the shadows of the diva, DNA. I know that firsthand: I was slaving away in obscurity on its behalf.

In the early 1980s, when I was much younger and most of the promise of RNA was still unimagined, I set up my lab at the University of Colorado, Boulder. After two years of false leads and frustration, my research group discovered that the RNA we’d been studying had catalytic power. This means that the RNA could cut and join biochemical bonds all by itself — the sort of activity that had been thought to be the sole purview of protein enzymes. This gave us a tantalizing glimpse at our deepest origins: If RNA could both hold information and orchestrate the assembly of molecules, it was very likely that the first living things to spring out of the primordial ooze were RNA-based organisms.

That breakthrough at my lab — along with independent observations of RNA catalysis by Sidney Altman at Yale — was recognized with a Nobel Prize in 1989. The attention generated by the prize helped lead to an efflorescence of research that continued to expand our idea of what RNA could do.

In recent years, our understanding of RNA has begun to advance even more rapidly. Since 2000, RNA-related breakthroughs have led to 11 Nobel Prizes. In the same period, the number of scientific journal articles and patents generated annually by RNA research has quadrupled. There are more than 400 RNA-based drugs in development, beyond the ones that are already in use. And in 2022 alone, more than $1 billion in private equity funds was invested in biotechnology start-ups to explore frontiers in RNA research.

What’s driving the RNA age is this molecule’s dazzling versatility. Yes, RNA can store genetic information, just like DNA. As a case in point, many of the viruses (from influenza to Ebola to SARS-CoV-2) that plague us don’t bother with DNA at all; their genes are made of RNA, which suits them perfectly well. But storing information is only the first chapter in RNA’s playbook.

Unlike DNA, RNA plays numerous active roles in living cells. It acts as an enzyme, splicing and dicing other RNA molecules or assembling proteins — the stuff of which all life is built — from amino acid building blocks. It keeps stem cells active and forestalls aging by building out the DNA at the ends of our chromosomes.

RNA discoveries have led to new therapies, such as the use of antisense RNA to help treat children afflicted with the devastating disease spinal muscular atrophy. The mRNA vaccines, which saved millions of lives during the Covid pandemic, are being reformulated to attack other diseases, including some cancers . RNA research may also be helping us rewrite the future; the genetic scissors that give CRISPR its breathtaking power to edit genes are guided to their sites of action by RNAs.

Although most scientists now agree on RNA's bright promise, we are still only beginning to unlock its potential. Consider, for instance, that some 75 percent of the human genome consists of dark matter that is copied into RNAs of unknown function. While some researchers have dismissed this dark matter as junk or noise, I expect it will be the source of even more exciting breakthroughs.

We don’t know yet how many of these possibilities will prove true. But if the past 40 years of research have taught me anything, it is never to underestimate this little molecule. The age of RNA is just getting started.

Thomas Cech is a biochemist at the University of Colorado, Boulder; a recipient of the Nobel Prize in Chemistry in 1989 for his work with RNA; and the author of “The Catalyst: RNA and the Quest to Unlock Life’s Deepest Secrets,” from which this essay is adapted.

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• Science and Technology Directorate

Feature Article: FloodAdapt Will Help Protect Flood-prone Communities

The Science and Technology Directorate (S&T) has partnered with Deltares USA to conduct demonstrations, trainings, and performance testing for the new accessible compound flood and impact assessment tool, which will help at-risk communities better prepare for and respond to severe weather events.

Our coastal communities have taken a real hit in recent years. With extreme weather events on the rise, learning from past incidents and emerging trends is the key to protecting lives and property. Having the right compound flood modeling systems and data in place to study, simulate, and predict threats makes collaboration and critical decision-making that much easier, so when the time comes, response can be swift.

S&T has been working with Deltares USA and the city of Charleston, South Carolina, for two years to develop and pilot a state-of-the-art suite of community-oriented flood-hazard modeling and impact assessment technologies and software that will soon be available to inform field operations and emergency response before and after any events make landfall. The tools, now collectively known as FloodAdapt , will provide responders, emergency managers, and policy makers in flood-prone communities with capabilities to establish stronger planning and preparation strategies.

“Our efforts in Charleston have played a critical role in the ongoing development of FloodAdapt,” said S&T Program Manager Ron Langhelm. “Thanks to engagement with local emergency managers, first responders, and community decision makers, along with continual performance and user testing, we’ve been able drastically improve upon FloodAdapt’s tools, and enhance their capabilities and scope of use.”

FloodAdapt has unique, user-friendly components that help users create community-specific flood simulations, study related impacts, and investigate the efficacy of potential preventive and mitigative efforts and responses.

SFINCS is an open-source modeling tool that rapidly and dynamically simulates compound flooding events that impact large-scale coastal environments, and calculates interactions between related phenomena such as rainfall, storm surges, and river discharge. Delft-FIAT is an open-source flood impact assessment modeling tool that evaluates flood damage to buildings, utilities, and roads.

FloodAdapt incorporates innovative decision-support features, helping bring them into practice. These include an equity-weighting tool that (optionally) incorporates income data in determining equity-weighted damages and risk, infographics that use social vulnerability data to evaluate the equitable distribution of impacts and benefits, and a benefits calculator to assess the risk-reduction benefits of measures or strategies that will help lessen the impact of future flood events.

“With these advanced capabilities, FloodAdapt is able to provide some of the most accurate flood-related models, infographics, and infometrics that are currently available,” explained Langhelm. “Users can integrate FloodAdapt into their own toolsets and plug in publicly available data or use their own. They can then study past weather events, simulate hypothetical scenarios, and evaluate vulnerabilities, risks, and mitigation strategies that are the most relevant to their needs or interests.”

While it is currently being piloted for coastal flooding research in Charleston, Langhelm and the Deltares team are working hard to raise awareness about and further improve FloodAdapt before it transitions to the field.

“Continuing to spread awareness about, improve, and develop new innovations for FloodAdapt are major priorities for us,” said Langhelm. “We want to make sure that it will always be accessible and useful to anyone who may want to use it—whether they are government organizations, academia, emergency managers and responders, or just everyday citizens who have their own interest in learning about flood modeling and research.”

To meet these goals, in March 2024 the Deltares team conducted demonstrations, trainings, and performance testing with members of the flood research and response communities in Charleston and Baltimore. Both trips were a great success.

“FloodAdapt made quite an impression in Charleston and Baltimore,” said Langhelm. “Our emergency managers in South Carolina were impressed with the improvements we’ve made and the capabilities we’ve added and are looking forward to using them with their current models and datasets as a part of their future flood research and planning efforts.”

“Our colleagues in Maryland weren’t as familiar with FloodAdapt,” continued Langhelm. “However, they found it to be a powerful, user-friendly tool, and believe that it can play a key role in their current flood research and mitigation efforts. We are preparing additional training materials for them so that they can continue to get more comfortable with FloodAdapt and eventually teach their regional partners how to use it as well.”

The team has also been consulting with academia to make FloodAdapt even more effective in the field.

“We’re working with the George Washington University to study income, population, and other related factors, and looking at how these social indicators should be better accounted for when implementing flood-related policies,” explained Langhelm. “And our colleagues at Dartmouth College’s School of Engineering have created an uncertainty framework for damage modeling, that, if incorporated into FloodAdapt, will help users more accurately predict the probability of a flood occurring in any given area.”

A growing number of international partners in the European Union, including the European Centre for Medium-range Weather Forecasts and emergency responders in Ireland and Denmark, are also interested in exploring ways to implement FloodAdapt into their regional and local coastal communities.

“All of these partnerships are critical,” said Langhelm. “Ultimately, we all have the same shared goal: to raise awareness about FloodAdapt and teach interested users how to effectively use it to enhance their communities’ resilience to flood events.”

In the coming year, the team will implement two new FloodAdapt capabilities to address technical gaps identified during recent user engagements: the ability to evaluate accessibility impacts (like access to a hospital) when roads are flooded and the ability to evaluate the damage-reduction effectiveness of coastal nature-based solutions (like coral reefs and coastal wetlands that serve as buffers from waves and high-tides).

Findings from the Charleston pilot will be documented in a peer-reviewed paper. The team is also creating and disseminating a series of FloodAdapt tutorial videos and technical manuals.

“The paper will serve as another means of spreading the word about FloodAdapt and its utility, while the videos and manuals will be valuable resources to anyone who is interested in accessing and using FloodAdapt,” explained Langhelm.

Each video will provide a brief overview of a specific functionality and demonstrate how it can be used, while the online technical manuals, which can be accessed directly from within FloodAdapt, will offer complementary written instruction.

S&T and Deltares plan to make FloodAdapt available to the public this October and will continue to expand upon, enhance, and promote it based on continual feedback from stakeholders in the flood research community.

For related media requests, please contact [email protected] . Visit S&T’s Community and Infrastructure Resilience page to learn more about our ongoing flood-related research and development efforts.

• Science and Technology