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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, lingmin chen.

1 Department of Anesthesiology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University and The Research Units of West China, Chinese Academy of Medical Sciences, Chengdu, China

2 Department of Medical Administration, West China Hospital, Sichuan University, Chengdu, China

Yonggang Zhang

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

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

5 Department of Periodical Press and National Clinical Research Center for Geriatrics & Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China

Associated Data

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.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12630-022-02363-5.

Résumé

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

Méthode

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

Résultats

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

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.

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 – 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 – 11 Especially during the COVID-19 pandemic, anesthesiologists played important roles 12 – 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. ​ (Fig.1). 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. ​ Fig.2 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 ​ Figure3 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. ​ (Fig.4), 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.

Below is the link to the electronic supplementary material.

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.

Acknowledgments

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).

Editorial responsibility

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

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Local infiltration anesthesia versus epidural analgesia for postoperative pain control in total knee arthroplasty: a systematic review and meta-analysis

• Chen Li 1 ,
• Su Pan 1 &
• Yang Qu 1  

Journal of Orthopaedic Surgery and Research volume  13 , Article number:  112 ( 2018 ) Cite this article

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We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of local infiltration anesthesia (LIA) versus epidural analgesia (EPA) for postoperative pain control in total knee arthroplasty (TKA).

In December 2017, a systematic computer-based search was conducted in Pubmed, EMBASE, Web of Science, and Cochrane Database of Systematic Reviews. RCTs of patients prepared for spine surgery that compared LIA versus EPA for postoperative pain control in TKA were retrieved. The primary endpoint was the VAS score with rest or mobilization at 12, 24 and 48, and 72 h. The secondary outcomes were the range of motion, the length of stay, and the occurrence of infection and nausea. After testing for publication bias and heterogeneity between studies, data were aggregated for random-effects models when necessary.

Seven clinical studies with 251 patients (LIA = 124, EPA = 127) were included in the meta-analysis. There was no significant difference between LIA and EPA group in terms of the VAS score with rest at 12 and 24 h. LIA was associated with a reduction of the VAS score with rest at 48 and 72 h than EPA ( P  < 0.05). There was no significant difference between the LIA group and EPA group in terms of the VAS with mobilization at 24, 48, and 72 h ( P  > 0.05). And LIA was associated with an increase of the range of motion at 24 and 48 h ( P  < 0.05) and a reduction of the length of hospital stay ( P  < 0.05). What is more, LIA was associated with a reduction of the occurrence of the nausea.

Conclusions

LIA has equivalent efficacy as EPA for pain control after TKA and shows an increase of the range of motion and a reduction of the occurrence of nausea and length of hospital stay. Due to the limited number of the included studies, more high-quality RCTs are still needed to identify the long-term effects of LIA for pain control after TKA.

Total knee arthroplasty (TKA) is a commonly performed procedure today. It was reported that over 700,000 joint replacements are performed in the USA each year [ 1 ]. However, postoperative analgesia remains a challenging issue. More than half of the patients undergoing TKA would experience severe pain in the early postoperative period [ 2 , 3 , 4 ]. Appropriate pain control is a prerequisite to promoting early mobilization and functional recovery after TKA. Several options are available for postoperative pain management following TKA, but all of them have shortcomings.

Epidural analgesia consisting of a local anesthetic agent and an opioid has been a regular regimen used for postoperative analgesia after TKA. However, some studies have indicated that the benefit of epidural analgesia must be weighed against the frequency of its adverse effects such as urinary retention, hypotension, pruritus, and motor block that delays mobilization.

In recent years, there is a growing interest in the use of local infiltration analgesia (LIA) containing various constituents as a modality of postoperative pain control. The advantage of LIA is the ability to provide pain control without interfering with lower extremity motor strength, thereby allowing early mobilization of patients. Studies have shown that LIA is consistently more effective in the treatment of postoperative pain after TKA when compared with placebo. There was still controversy about which protocol is more suitable for pain control after TKA. Therefore, we searched for relevant studies and performed a meta-analysis comparing LIA versus epidural anesthesia for reducing pain intensity in TKA patients.

This systematic review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Search strategies

The following databases were searched in November 2017 without restriction of regions or publication types: Pubmed (1950–November 2017), EMBASE (1974–November 2017), Web of Science (1950–November 2017), and Cochrane Library (November 2017 Issue 3). The Mesh terms and their combinations used in the search were as follows: “local infiltration anesthesia” OR “LIA” OR “epidural anesthesia” OR “EPA” AND “((((“Arthroplasty, Replacement, Knee”[Mesh]) OR TKR) OR TKA) OR total knee replacement)” OR total knee arthroplasty. The reference lists of related reviews and original articles were searched for any relevant studies, including randomized controlled trials (RCTs) involving adult humans. Only articles originally written in English or translated into English were considered. When multiple reports describing the same sample were published, the most recent or complete report was used. Since this is a meta-analysis, no ethics committee or institutional review board approval was necessary for the study.

Inclusion criteria and study selection

The following are included in the study: patients: adult human subjects prepared for TKA; intervention: LIA as an intervention group; comparison: EPA as a control group; outcomes: visual analogue scale (VAS) with rest or mobilization at 12, 24, 48, and 72 h, the length of hospital stay, and the occurrence of nausea and infection; and study design: RCTs. Two independent reviewers screened the title and abstracts of the identified studies after removing the duplicates of the search results. Any disagreements about the inclusion or exclusion of a study were solved by discussion or consultation with an expert. The reliability of the study selection was determined by Cohen’s kappa test, and the acceptable threshold value was set at 0.61 [ 5 , 6 ].

Data abstraction and quality assessment

A specific extraction was conducted to collect the following data from the included trials: patients’ general characteristics, country, the sample size of the control group and intervention group, and the drug and dose of LIA and EPA. Outcomes such as VAS with rest or mobilization at 12, 24, 48, and 72 h; the length of hospital stay; and the occurrence of nausea and infection were abstracted and recorded in a sheet. Postoperative pain intensity was measured by a 100-point VAS. When the numerical rating scale (NRS) was reported, it was converted to a VAS. Additionally, a 10-point VAS was converted to a 100-point VAS [ 7 ]. Data in other forms (i.e., median, interquartile range, and mean ± 95% confidence interval (CI)) were converted to the mean ± standard deviation (SD) according to the Cochrane Handbook [ 8 ]. If the data were not reported numerically, we extracted these data using “GetData Graph Digitizer” software from the published figures. All the data were extracted by two independent reviewers, and disagreements were resolved by discussion. The methodological quality of all included trials was independently assessed by two reviewers on the basis of the Cochrane Handbook for Systematic Reviews of Interventions, version 5.1.0 ( http://www.cochrane-handbook.org/ ).

Outcome measures and statistical analysis

Continuous outcomes (VAS with rest or mobilization at 12, 24, 48, and 72 h and the length of hospital stay) were expressed as the weighted mean differences (WMD) and respective 95% CI. Dichotomous outcomes (the occurrence of nausea and infection) were expressed as the risk ratio (RR) with 95% CI. Statistical significance was set at P  < 0.05 to summarize the findings across the trials. The meta-analysis was calculated by Stata software, version 12.0 (Stata Corp., College Station, TX). Statistical heterogeneity was tested using the chi-squared test and I 2 statistic. When there was no statistical evidence of heterogeneity ( I 2  < 50%, P  > 0.1), a fixed-effects model was adopted; otherwise, a random-effect model was chosen. Publication bias was tested using funnel plots. Publication bias was assessed by funnel plot and quantitatively assessed by Begg’s test. We considered there to be no publication bias if the funnel plot was symmetrical and the P value was > 0.05.

Grade of evidence

The quality of evidence for each finding was rated based on criteria established by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) group [ 9 ]. The RCTs was considered as high-quality evidence, which could be downgraded to moderate, low, or very low quality for five reasons (high risk of bias, inconsistent results, indirect evidence, imprecision, and publication bias). Any disagreement was settled by discussion among the research team.

Search results and quality assessment

Figure  1 details the study search and selection process. In the initial research, a total of 359 papers were identified from the electronic databases (PubMed = 205, Embase = 71, Web of Science = 50, and Cochrane Library = 33). The number of articles after duplicates had been removed by Endnote X7 software was 203. After screened the abstracts and title of these 203 studies, 196 papers were excluded because they were irrelevant or did not meet the criteria. Finally, a total of seven clinical studies involving 251 patients (LIA = 124, EPA = 127) were included in this meta-analysis [ 10 , 11 , 12 , 13 , 14 , 15 , 16 ]. The general characteristic of the included studies can be seen in Table  1 . Included studies published from the year of 1995 to the year of 2015. And the sample of the included studies ranged from 15 to 61.

Flowchart of study search and inclusion criteria

The risk of bias summary and risk of bias graph can be seen in Figs.  2 and  3 . The random sequence generation was low risk of bias in five studies, and two studies were unclear risk of bias. The allocation concealment were low risk of bias in four studies, high risk of bias in one study, and unclear risk of bias in the rest of the studies. The blinding of participants and outcomes assessment were unclear risk of bias in four studies and the selection reporting were low risk of bias in all of the included studies.

Risk of bias summary of included randomized controlled trials. +, no bias; −, bias; ?, bias unknown

The risk of bias graph

VAS with rest at 12, 24, 48, and 72 h

Postoperative VAS scores with rest at 12 h were reported in six studies, and the pooled results indicated that there was no significant difference between the LIA and EPA group in terms of the VAS score with rest at 12 h (WMD = − 0.21, 95% CI − 0.61, 0.18, P  = 0.288, Fig.  4a ). There were a total of seven clinical studies performing the results of VAS score with rest at 24 h. Results indicated that there was no significant difference between the two groups as regard to the VAS score with rest at 24 h (WMD = − 0.29, 95% CI − 0.94, 0.37, P  = 0.386, Fig.  4b ). VAS score with rest at 48 h were available in five studies, and pooled results indicated that LIA was associated with a reduction of the VAS score with rest at 48 h than EPA (WMD = − 1.09, 95% CI − 2.09, − 0.09, P  = 0.032, Fig.  4c ). VAS score with rest at 72 h were available in five studies, and pooled results indicated that LIA was associated with a reduction of the VAS score with rest at 72 h than EPA (WMD = − 0.88, 95% CI − 1.29, − 0.46, P  = 0.000, Fig.  4d ).

Forest plots of the included studies comparing the VAS with rest at 12 h ( a ), 24 h ( b ), 48 h ( c ), and 72 h ( d )

VAS with mobilization at 24, 48, and 72 h

There were no significant differences between the LIA group versus EPA group in VAS score with mobilization at 24 h (WMD = 0.08, 95% CI − 1.88, 2.05, P  = 0.934, Fig.  5a ), 48 h (WMD = − 0.45, 95% CI − 2.25, 1.36, P  = 0.627, Fig.  5b ) and 72 h (WMD = − 1.25, 95% CI − 2.54, 0.05, P  = 0.060, Fig.  5c ).

Forest plots of the included studies comparing the VAS with mobilization at 24 h ( a ), 48 h ( b ), and 72 h ( c )

Range of motion at 24, 48, and 72 h

Meta-analysis results indicated that LIA was associated with an increase of the range of motion than EPA at 24 h (WMD = 5.44, 95% CI 0.29, 10.79, P  = 0.039, Fig.  6 ) and 48 h (WMD = 5.21, 95% CI 1.01, 9.42, P  = 0.015, Fig.  6 ). The pooled results indicated that there was no significant difference between LIA group and EPA in terms of range of motion at 72 h (WMD = − 1.25, 95% CI − 2.54, 0.05, P  = 0.060, Fig.  6 ).

Forest plots of the included studies comparing the range of motion at 24, 48, and 72 h

Length of hospital stay

Meta-analysis results indicated that LIA was associated with a reduction of the LOS than EPA (WMD = − 1.71, 95% CI − 3.12, − 0.30, P  = 0.018, Fig.  7 ).

Forest plots of the included studies comparing the length of hospital stay between the two groups

The occurrence of nausea and infection

Meta-analysis results indicated that LIA was associated with a reduction of the occurrence of nausea than EPA (RR = 0.38, 95% CI 0.26, 0.57, P  = 0.000, Fig.  8 ). There was no significant difference between the LIA group and EPA group in terms of the occurrence of infection (RR = 1.98, 95% CI 0.50, 7.81, P  = 0.331, Fig.  9 ).

Forest plots of the included studies comparing the occurrence of nausea between the two groups

Forest plots of the included studies comparing the occurrence of infection between the two groups

Grade of evidence was low in VAS with rest or mobilization at 12, 24, 48, and 72 h. And the grade of evidence was high in the length of hospital stay and the occurrence of nausea and infection. Grade of evidence was middle in the range of motion at 24, 48, and 72 h.

Publication bias, sensitivity analysis, and subgroup analysis

Funnel plot analyses on VAS with rest at 12, 24, 48, and 72 h demonstrated symmetry, suggesting that bias was minimal (Fig.  10 ). Firstly, we applied leave-out method by excluding some studies to reduce between-study heterogeneity, thereby making a more robust conclusion (Fig.  11 ). The conclusions remained unchanged in all outcomes, suggesting the stability of our meta-analysis. We further conducted a subgroup analysis for VAS scores (single-shot LIA or continuous LIA). Subgroup result of VAS with rest at 12, 24, 48, and 72 h was shown in Additional file  1 : Figure S1. Subgroup difference was found in VAS with rest at 48 h (single-shot LIA, WMD = − 2.80, 95% CI − 3.94, − 1.66, P  = 0.000; continuous LIA, WMD = − 0.69, 95% CI − 1.51, 0.12, P  = 0.093). VAS with mobilization at 24, 48, and 72 h was shown in Additional file  2 : Figure S2. Subgroup difference was found in VAS with mobilization at 48 and 72 h.

Funnel plot that comparing the VAS with rest at 12, 24, 48, and 72 h

Sensitivity analysis of the VAS with rest at 12 h

Summary of the main finding

Current meta-analysis indicated that LIA has an equivalent efficacy for pain relieving with rest of mobilization at early period and late period than EPA after TKA. LIA was associated with an increase of the range of motion than EPA at an early period after TKA. And LIA was associated with a reduction of the occurrence of nausea and the length of hospital stay than EPA. There was no significant difference between the occurrence of infection. Yan et al. [ 17 ] conducted a recent meta-analysis of RCTs showing that LIA achieves better analgesic effects comparing with EPA. However, it contained some methodological shortcomings, errors in inclusion criteria (TKA and total hip arthroplasty (THA)) and data extraction, and high heterogeneity. Considering all these issues, it is impossible to give clear advice on which method to adopt.

Pain intensity was measured as VAS score at 12, 24, 48, and 72 h after TKA. Choi et al. [ 18 ] performed a Cochrane review and revealed that EPA may be useful for postoperative pain relief at early (four to 6 h) postoperative period following TKA. These results were in accordance with our main results. Jiménez-Almonte et al. [ 19 ] using the novel statistical network meta-analysis approach and found no differences between LIA and EPA in terms of analgesia or opioid consumption 24 h after total hip arthroplasty.

With respect to the range of motion of the knee, we found that LIA was superior than EPA in the early period after TKA. These may not be an indicator of favorable pain control in the LIA group. It is more likely attributed to the absence of motor block. As a result, early functional recovery will be strengthened by functional quadriceps [ 20 ].

Current meta-analysis also compared the occurrence of nausea and infection. Epidural analgesia consisting a variety of opioids and identified has a beneficial role in reducing pain intensity after surgeries. However, the results of many studies showed a high frequency of nausea or vomiting [ 21 ]. local anesthesia was accepted as the gold standard for postoperative pain control after the report by Bromage et al. [ 22 ]. Results shown that LIA was associated with a reduction of the occurrence of nausea than EPA. More nausea has been reported to occur with morphine than with local infiltration anesthesia [ 23 , 24 ]. This can be considered a disadvantage of the epidural method. In terms of wound infection, incidences were comparable between groups and kept at low level. There was no significant difference between the occurrence of infection.

Limitations and strengths

Our meta-analysis also has several potential limitations that should be taken into account when considering the benefits. First, our analysis comprised only seven RCTs, but one of them had a modest sample size ( n  < 100). Compared to large sample size studies, small sample size studies are inclined to overestimate the intervention effect [ 25 ], which limits the power of inference. Second, although the effect size in the funnel plot was symmetrical, we could not exclude the publication bias due to the small number of the included studies. Meanwhile, the relative short follow-up duration will underestimate the complications.

Although the overall quality of the evidence can be considered “middle,” we objectively assessed the benefits and risk of LIA and EPA. Based on this meta-analysis of all currently published RCTs, the findings have important implications for the medical community, namely, that LIA is an effective alternative to provide less length of hospital stay and nausea but provides comparable level of pain relief in comparison with the EPA.

Abbreviations

Confidence interval

Epidural analgesia

• Local infiltration anesthesia

Numerical rating scale

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Randomized controlled trials

Standard deviation

Total hip arthroplasty

• Total knee arthroplasty

Visual analogue scale

Weighted mean differences

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Additional files

Additional file 1:.

Figure S1. Subgroup analysis of the VAS with mobilization at 24, 48, and 72 h (single-shot local infiltration anesthesia or continuous local infiltration anesthesia, A VAS with rest at 24 h, B VAS with rest at 48 h, and C VAS with rest at 72 h). (DOCX 1384 kb)

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Figure S2. Subgroup analysis of the VAS with rest at 12, 24, 48, and 72 h (single-shot local infiltration anesthesia or continuous local infiltration anesthesia, A VAS with rest at 12 h, B VAS with rest at 24 h, C VAS with rest at 48 h, D VAS with rest at 72 h). (DOCX 2027 kb)

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Li, C., Qu, J., Pan, S. et al. Local infiltration anesthesia versus epidural analgesia for postoperative pain control in total knee arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res 13 , 112 (2018). https://doi.org/10.1186/s13018-018-0770-9

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Department of Anesthesiology, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China

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Wu, M., Shi, B. Letter to the article by Oh et al.. J Anesth (2024). https://doi.org/10.1007/s00540-024-03353-1

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Received : 21 May 2024

Accepted : 24 May 2024

Published : 01 June 2024

DOI : https://doi.org/10.1007/s00540-024-03353-1

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Neuroanesthesia : A Problem-Based Learning Approach

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Jamie L. Uejima , John F. Bebawy; Neuroanesthesia : A Problem-Based Learning Approach . Anesthesiology 2019; 131:221 doi: https://doi.org/10.1097/ALN.0000000000002767

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Neuroanesthesia: A Problem-Based Learning Approach is a welcome addition to the literature in the sometimes unapproachable and often dry world of instructional materials designed for those desiring to further their neuroanesthesia skills, education, and training. By using a problem-based learning approach, David E. Traul and Irene P. Osborn have taken the complex world of neuroanesthesia and broken it down into digestible and applicable cases, not only for those studying for board exams, but also for those anesthesiologists and trainees who seek a quick “refresher” in many facets of neuroanesthesia. The 29 high-yield case-based chapters cover a wide variety of topics and are well organized into sections ( e.g. , oncologic procedures, vascular procedures, spine procedures, functional procedures, neuroanesthesia concepts). The chapters each begin with a case stem followed by a series of key questions designed to mimic an oral board exam. The chapters end with a more generalized discussion that delves into greater depth and breadth regarding the preoperative, intraoperative, and postoperative concerns related to these surgeries and anesthetics. Each chapter has 10 additional questions with answers available online in a full practice exam.

Like many books that take a case-based approach to instruction, there are formatting issues and inconsistencies between chapters that are distracting at times. For instance, some chapters follow each question with its specific answer, while others “answer the question” more broadly without reference to the question asked. Additionally, the chapters range in quality and depth from excellent and fact-based to largely opinion-based or institution-biased management regarding both case management and review of the pertinent literature. The quality and currency of references also vary widely from chapter to chapter. That being said, the book achieves its goals of palatably providing key elements to instruct both the trainee and the experienced anesthesiologist in safely managing neuroanesthetic cases in the “real world,” as well as tackling the key neuroanesthetic concepts that inevitably appear on in-training and board exams.

As far as readability, Neuroanesthesia: A Problem-Based Learning Approach is a very approachable resource and is easy to read, with helpful figures and tables providing high-yield information throughout the chapters. The authors also use the cases presented to delve into and discuss some pertinent neuroanesthetic complications, such as a venous air embolism, and basic, practical neuroanesthesia concepts, like anesthetic regimens to facilitate neurophysiological monitoring. Although a more comprehensive list of topics for neuroanesthetic complications and general concepts would have been ideal, by including these sections within the cases, the book becomes more than simply a “primer” for anesthesia for neurosurgical procedures, as many of the books in the subspecialty tend to be.

Overall, Neuroanesthesia: A Problem-Based Learning Approach provides high-yield, problem-based neuroanesthesia instruction in a very readable format and is a useful resource for those looking for a timely, engaging, and not overly burdensome review of the subspecialty.

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Publications in anesthesia journals: quality and clinical relevance

Affiliation.

• 1 Department of Anesthesia, Herlev University Hospital, Herlev, Denmark.
• PMID: 15502053
• DOI: 10.1213/01.ANE.0000136468.92993.CF

Clinicians performing evidence-based anesthesia rely on anesthesia journals for clinically relevant information. The objective of this study was to analyze the proportion of clinically relevant articles in five high impact anesthesia journals. We evaluated all articles published in Anesthesiology, Anesthesia & Analgesia, British Journal of Anesthesia, Anesthesia, and Acta Anaesthesiologica Scandinavica from January to June, 2000. Articles were assessed and classified according to type, outcome, and design; 1379 articles consisting of 5468 pages were evaluated and categorized. The most common types of article were animal and laboratory research (31.2%) and randomized clinical trial (20.4%). A clinically relevant article was defined as an article that used a statistically valid method and had a clinically relevant end-point. Altogether 18.6% of the pages had as their subject matter clinically relevant trials. We compared the Journal Impact Factor (a measure of the number of citations per article in a journal) and the proportion of clinically relevant pages and found that they were inversely proportional to each other.

• Anesthesiology / standards*
• Anesthesiology / trends*
• Clinical Trials as Topic
• Data Collection
• Meta-Analysis as Topic
• Models, Statistical
• Publishing / standards*
• Randomized Controlled Trials as Topic
• Research Design
• Review Literature as Topic
• Treatment Outcome