Alcohol consumption is associated with dose-dependent health loss secondary to long-term intake. In this scoping review, we sought to synthesize the literature on the association between the dose of preoperative alcohol consumption and postoperative outcomes. We included studies with adults undergoing cardiac and major noncardiac surgery reporting the dose of preoperative alcohol and postoperative outcomes. We searched MEDLINE, Embase®, and Cochrane Databases for Controlled Trials and Systematic Reviews. Outcomes were mortality, intensive care unit (ICU) admission, length of stay (LOS), delirium, surgical site infection (SSI), major cardiac and renal events, and postoperative pulmonary complications (PPCs). We assessed risk of bias (ROB) using the Newcastle–Ottawa Scale (cohort) and Joanna Briggs Institute tool (cross-sectional). We registered the protocol at PROSPERO (CRD42023474001). Of 9,591 references, we included 23 studies, and 7 exhibited high ROB. When consumed regularly, alcohol was associated with an increase in postoperative mortality (three of six studies), ICU admission (two of three studies), LOS (four of six studies), delirium (one of four studies), SSI (five of nine studies), and PPCs (one of three studies). No meaningful change in the results emerged when the high-ROB studies were removed. No consistent threshold of alcohol consumption was evident, though some studies implied an association with a dose of ≥ 2 drinks equivalents·day−1. Renal (one study) and cardiac complications (three studies) were not linked with preoperative alcohol consumption. The association between alcohol dose and postoperative complications is inconsistent across observational studies.
In this study, we aimed to evaluate the incidence and anticipation rate of difficult airways in adult nonobstetric patients undergoing general anesthesia at a single tertiary–quaternary Australian hospital, and to review the predictors of difficult airways and the impact of videolaryngoscopy (VL) on glottic visualization in unanticipated difficult airway cases. We conducted a retrospective observational study over a 6-month period. We included 5,293 adult patients who underwent general anesthesia with airway instrumentation. Data was extracted from anesthetic records. Difficult airways were defined according to the Canadian Airway Focus Group criteria. Cases of difficult airways were classified as anticipated or unanticipated on the basis of preoperative airway assessments. Of 5,293 patients, 207 (4
Limited evidence exists to inform opioid selection in patients in the intensive care unit (ICU) receiving mechanical ventilation, and current guidelines treat opioids as interchangeable. We sought to describe temporal trends in, and factors associated with, the choice of first opioid infusion in critically ill patients. We conducted a historical cohort study of patients receiving mechanical ventilation (MV) in ICUs in Alberta, Canada, 2013–2019. We included patients who received a first continuous infusion of fentanyl, hydromorphone, or morphine. We assessed temporal trends and used a multilevel multinomial logistic regression model to identify patient-level factors associated with opioid choice, as well as ICU-level variability using the adjusted median odds ratio (aMOR). Among 17,898 admissions in 20 ICUs who met inclusion criteria, fentanyl was the most frequent initial opioid infusion (78.6
Despite considerable effort, concerns over the quality of the outcomes of resuscitation preference conversations continue. In part, the problem relates to inadequate attention to conversation complexity and the development of oversimplified guides. We aimed to develop a more nuanced understanding of the complexity of real-world resuscitation preference conversations that examines the multiple challenges encountered. We used Charmazian-constructivist grounded theory to analyze 106 clinical notes from a data set of 366 detail-rich resuscitation preference conversation narratives. Sampling was purposive and focused on maximum variation. Rigor was enhanced through iterative data collection and analysis and constant comparison. All conversations could be described as one of five typologies (standard or middle ground, fighter, conflict or conflicted, avoidance or deferral, and wrong conversation) and two modifiers (re-exploration and health care team concerns about preference) that provide insights into the patients’ rationale for decision-making. We also identified 28 conversation foci, which appeared necessary to address, when present, to continue with the conversations (e.g., denial or family conflict). Conversations also benefited from the expression of health care team concern with choice, when needed. Addressing what-if and what-next provided additional nuance on how to proceed postresuscitation, especially for challenging conversations. The strategy of structuring and engaging with various conversation foci and typologies as they arise, and the importance of exploring what-if and what-next are important additions to the literature and existing guides. Our findings add to existing resources in ways that can hopefully be used to improve clinical practice and training.
We aimed to evaluate the phase-dependent agreement between continuous noninvasive blood pressure monitoring using ClearSight™ (Edwards Lifesciences Corp., Irvine, CA, USA) and invasive arterial pressure (IAP) across distinct intraoperative phases of transcatheter aortic valve replacement (TAVR). We conducted a single-centre observational study at a tertiary academic hospital performing TAVR. We included 21 patients undergoing TAVR, contributing 987 paired invasive and noninvasive blood pressure measurements. We recorded noninvasive blood pressure monitoring using ClearSight concurrently with standard IAP monitoring as part of routine clinical care. We analyzed repeated paired measurements using Bland–Altman methods extended with linear mixed-effects modeling, with additional sensitivity analyses performed to assess robustness. We compared invasive and ClearSight-derived systolic, mean, and diastolic pressures. ClearSight underestimated systolic and mean pressures and overestimated diastolic pressure. After excluding outliers identified by quantile–quantile plot diagnostics, mean biases (IAP minus ClearSight) were +14 mm Hg (systolic), +6 mm Hg (mean), and −3 mm Hg (diastolic). Limits of agreement narrowed after outlier removal, and intraclass correlation coefficients improved (systolic, 0.69 to 0.72; mean, 0.65 to 0.68; diastolic, 0.59 to 0.63). Phase-specific analysis showed the widest disagreement during induction/stabilization, improved accuracy during valve deployment, and the best agreement, particularly for mean arterial pressure, after protamine administration, when vascular tone and hemodynamic stability were restored. ClearSight showed phase-dependent agreement with IAP during TAVR, typically underestimating systolic and mean pressures, with improved agreement during hemodynamic stability, most notably after protamine. These findings support ClearSight as an adjunct rather than a replacement for invasive arterial monitoring during TAVR. Broader validation studies are warranted.
Diagnosing acute respiratory distress syndrome (ARDS) traditionally relies upon chest radiography or computed tomography for radiologic criteria. Recent recommendations have proposed lung ultrasonography (LUS) as an alternative modality; however, the evidence supporting its utility remains uncertain. We sought to conduct a systematic review to evaluate the diagnostic accuracy of LUS for ARDS. We searched MEDLINE, CINAHL, Embase®, and the Web of Science™ from inception through 16 May 2025, for original studies comparing the diagnostic accuracy of LUS to computed tomography or chest x-ray for ARDS diagnosis. We performed a diagnostic meta-analysis assessing lung ultrasound for ARDS, assessed the risk of bias of included studies using the QUADAS-2 tool, and rated the certainty of evidence using GRADE methodology. Our systematic review included 22 studies comparing LUS with a reference test using different scanning protocols and diagnostic thresholds, with variable interrater reliability. We included 13 studies in the meta-analysis (n = 1,999 patients, of which 618 [30.9 CRD42023468933 ); first submitted 5 October 2023.
Insufficient resources and dynamic infection control policies during the COVID-19 pandemic necessitated that frontline health care providers (HCPs) make frequent ethical decisions about the allocation of scarce supplies, space, and clinician time to patient care activities. We aimed to understand the process, nature, and impact of these resource allocation decisions. Using a qualitative case study approach, we developed an understanding of the decision-making of frontline intensive care unit (ICU) HCPs during the pandemic. We conducted 25 semistructured interviews with multidisciplinary HCPs employed in a community ICU in Ontario, Canada. We then extracted data related to resource allocation decisions and analyzed it within-case, using conventional (inductive) content analysis. Ethical decisions about resource allocation were ubiquitous for all types of HCPs within critical care practice. The constraints imposed by the pandemic and multiple provincial and organizational policies formed the context that necessitated these decisions. Health care providers drew upon a range of values in their decision-making, typically prioritizing HCP safety and patient well-being. Resulting actions included prioritizing clinical tasks, establishing boundaries, and modifying practice patterns. Although these situations commonly evoked stress and frustration among HCPs, feelings of self-efficacy, resourcefulness, and team cohesion were also described. Institutional policies and pragmatic limitations meant that HCPs in a community ICU in Ontario, Canada needed to make frequent ethical decisions about the allocation of scarce resources during the pandemic. These frequent decisions highlight the degree to which resource allocation is an inherent part of critical care. There is opportunity for targeted professional development to support allocation practices during adverse circumstances.
Protocol registration is essential for preventing selective reporting bias in systematic reviews, yet deviations from registered protocols remain common across medical fields. We sought to evaluate the prevalence of protocol registration and assessed concordance between registered protocols and published systematic reviews in high-impact anesthesiology journals, hypothesizing that undeclared deviations would be prevalent. We conducted a cross-sectional analysis of systematic reviews published in 2025 in first-quartile anesthesiology journals according to Journal Citation Reports (Clarivate, London, UK). We searched PubMed® in July 2025 to identify eligible studies. Two reviewers independently assessed concordance between registered protocols and published reviews using a standardized 22-item extraction form covering eligibility criteria; the Population, Intervention, Comparison, Outcome, and Study Design (PICOS) framework; search methods; risk assessment tools; and planned analyses. We recorded agreement as binary outcome, with explicit acknowledgement of deviations noted. Of 172 identified systematic reviews, we included 114 after excluding nonregistered studies and those with post hoc registration. All 114 (100 https://osf.io/ksezg ); first submitted 10 July 2025.
Ultrasound-guided regional anesthesia (UGRA) requires knowledge of anatomy, hand–eye coordination, and safe needling techniques. Extended reality (XR), including augmented reality, virtual reality (VR), and mixed reality, is an emerging simulation modality for UGRA training. We sought to conduct a systematic review to evaluate the current evidence on the effectiveness of XR for UGRA training. We searched MEDLINE, Embase®, the Cochrane Library, Web of Science®, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) from inception to 15 November 2024. We included randomized controlled trials, observational studies, and case series. We categorized outcomes by Kirkpatrick levels and assessed risk of bias. From 1,703 articles, we included seven studies (N = 137 participants). Four studies reported participant reactions. One trial (n = 29) found higher self-confidence in anatomical landmark identification and procedural performance (P < 0.001). One study assessed knowledge, reporting a score increase (P < 0.001). Augmented reality head-mounted display studies found shorter procedure times (10 vs 7 sec; P = 0.03 and 18 vs 12 sec; P = 0.002), higher needle visibility (34 CRD42023424194 ); first submitted 18 May 2023.
We sought to conduct a scoping review to summarize the existing literature on environmental sustainability in critical care medicine, methods for measuring intensive care unit (ICU)-related environmental impact, and interventions to improve ICU environmental sustainability. We conducted a systematic search of four databases to identify studies published before October 2024 pertaining to environmental sustainability and assessment of the carbon footprint of ICUs and manually screened selected journals. The combined search strategy identified 1,967 potentially eligible articles. We conducted a full-text review of 149 articles, of which 99 met eligibility criteria. Articles were categorized into five domains: waste management (n = 31), carbon footprint (n = 20), sustainable medication practices (n = 9), energy delivery/consumption (n = 4), and other (n = 39), with four studies classified into two themes owing to overlap in content. Daily material waste in the ICU ranged from 4.9 to 15.2 kg per patient per day. Most studies reported poor waste sorting practices, and several studies reported reductions in waste generation with multicomponent interventions. Three carbon-footprint-themed studies calculated the carbon footprint of ICUs either through life-cycle assessments or material flow analysis. Eleven studies quantified carbon emission reductions using either prospective or theoretical stewardship interventions related to equipment, medications, or ICU care processes. In this scoping review, we found a rapidly expanding yet fragmented body of evidence on ICU environmental sustainability. Important gaps exist in evidence to guide clinicians on practical bedside strategies and understanding how to implement them to drive meaningful, sustainable change.
Diabetes mellitus (DM) is increasing in prevalence. Perioperative hyperglycemia is associated with an increased risk of adverse postoperative outcomes. We aimed to determine the prevalence of DM as well as the incidence of patients having a current hemoglobin A1C (HbA1C) and compare postoperative outcomes between patients with and without hyperglycemia. We performed a retrospective cohort study of adult patients undergoing noncardiac surgery at the University of Alberta Hospital (Edmonton, AB, Canada) between November 2019 and December 2023. We identified DM retrospectively using International Classification of Diseases, Ninth and Tenth Revision (ICD-9 and ICD-10), diagnosis codes. We evaluated HbA1C (90 days preceding admission) and the highest random glucose level on the operative day. We examined the unadjusted association of hyperglycemia with in-hospital mortality, 30-day mortality, and length of stay. We then undertook propensity-score-matched analysis. In adult patients, 42,996 noncardiac surgeries were performed. Of these, 9,421 (22
The climate crisis represents the single largest threat to human health of the twenty-first century. The environmental footprint of providing critical care can be reduced if clinicians and administrators have guidance on how to do so safely. We sought to develop evidence-based recommendations to safely reduce the environmental footprint of critical care medicine. A national Canadian multidisciplinary critical care medicine working group was convened to develop a list of climate-conscious recommendations for Choosing Wisely Canada. The working group developed and refined a list of recommendations between November 2023 and May 2024. Content experts and literature review informed the process. The working group used a three-stage structured anonymous voting process to select and refine the final list of recommendations. The multidisciplinary working group consisted of 23 clinicians, educators, and trainees. A preliminary list of 28 recommendations was developed over the course of two working group meetings in early 2024. The final refined list of seven recommendations was finalized in May 2024. Recommendations include 1) avoiding unnecessary disposable glove use, 2) only changing ventilator tubing and circuits when visibly soiled, 3) avoiding stocking surplus supplies in patient rooms, 4) using oral/enteral medications over intravenous preparations when appropriate, 5) avoiding single-use equipment when re-usable options are available, 6) removing isolation precautions when deemed safe by infection control, and 7) de-prescribing unnecessary medications on transfer out of the intensive care unit. This Special Article introduces seven Choosing Wisely Canada climate-conscious recommendations to empower clinicians in reducing the environmental impact of critical care medicine.
