Delphi methodology plays an important role in consensus development in areas where evidence is limited, ambiguous, or heterogeneous. However, the process remains inherently vulnerable to cognitive and methodological biases involving principal investigators, expert panellists, and other stakeholders. Recognising and proactively addressing these biases is essential to improve the rigour, transparency, and credibility of Delphi-based consensus research. Future efforts should focus on developing structured frameworks for transparent reporting and systematic implementation of bias mitigation strategies throughout the Delphi process.
Clinical practice guidelines and consensus statements are increasingly influential in anaesthesia, perioperative medicine, pain medicine, and critical care. Despite drawing upon similar evidence bases, recommendations frequently differ across countries, professional societies, and healthcare systems. Such variation may reflect differences in methodology, evidence appraisal, resource availability, patient populations, health policy, cultural context, and stakeholder priorities. To address this challenge, the British Journal of Anaesthesia is launching a new series that will systematically compare and synthesise international guideline documents, using structured appraisal frameworks.
BACKGROUND:This study aimed to explore the effect of intraoperative corticosteroid administration at antiemetic doses on postoperative pulmonary complications in adult patients undergoing major surgery. METHODS:We designed a post hoc analysis of two clinical trials conducted across 30 hospitals that included adult patients undergoing major abdominal or thoracic surgeries. Patients who received intraoperative corticosteroids were identified and balanced with those who did not receive corticosteroids using inverse probability of treatment weighting based on preoperative confounders. The primary outcome was a composite of postoperative pulmonary complications within 30 days after surgery. Generalised mixed-effects models with random intercepts at each hospital were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS:A total of 1963 patients were included. Before weighting for potential confounders, the incidence of severe postoperative pulmonary complications was lower in those who received corticosteroids than those who did not (9.3% [107/1142] vs 14.0% [113/821], P=0.002). After weighting, intraoperative corticosteroids were not associated with a significant reduction in the incidence of postoperative pulmonary complications (OR 0.86, 95% CI 0.62-1.18, P=0.347), but there was a modest improvement in partial pressure of oxygen in arterial blood-to-fraction of inspired oxygen ratios in the PACU in those who received intraoperative corticosteroids compared with those who did not (adjusted mean difference 19.9 mm Hg, 95% CI 0.64-39.1, corrected P=0.043). CONCLUSIONS:Corticosteroid administration at antiemetic doses in adult patients having major abdominal or thoracic surgery was not associated with a lower incidence of postoperative pulmonary complications. Postoperative pulmonary gas exchange marginally improved in patients receiving intraoperative corticosteroids. CLINICAL TRIAL REGISTRATION:NCT03182062 and NCT02798133.
BACKGROUND:Pulmonary complications occur frequently after cardiac surgery. Various intraoperative and perioperative mechanical ventilation strategies were investigated to reduce postoperative lung injury. Evidence of their benefits remains inconclusive. METHODS:We performed a systematic review and meta-analysis of RCTs investigating ventilation strategies applied during the preoperative, intraoperative, or postoperative period of cardiac surgery requiring cardiopulmonary bypass. The primary outcome was all-cause mortality. Secondary outcomes included the rate of infections, postoperative pulmonary complications, and the duration of mechanical ventilation. RESULTS:We identified 105 RCTs. We conducted a meta-analysis of the 39 studies suitable for quantitative synthesis. Postoperative pulmonary complications were reduced when using ventilation during cardiopulmonary bypass (risk ratio [RR]=0.87; 95% confidence interval [CI]=0.79 to 0.96; P=0.005; I2=0%, with 15 studies included). Mortality was 17/414 (4.1%) in patients receiving postoperative noninvasive respiratory support vs 24/377 (6.4%) in control group patients (RR=0.60; 95% CI=0.34 to 1.08; P=0.09; I2=0%, with five studies included). Pressure-controlled vs volume-controlled ventilation during surgery and adaptive support ventilation vs conventional ventilation in the postoperative period were not associated with improvements in primary or secondary outcomes. CONCLUSIONS:Ventilation strategies in cardiac surgery remain highly heterogeneous regarding protocols and timing. Ventilation during cardiopulmonary bypass significantly reduced postoperative pulmonary complications. Postoperative noninvasive respiratory support showed a non-significant trend toward improved survival and remains hypothesis-generating. Additional evidence is required to validate these results. REGISTRATION:PROSPERO registration number CRD420251057156.
Preoperative liquid fasting durations remain unacceptably long worldwide and represent one of the most common yet under-recognised sources of avoidable perioperative harm. Recent international multidisciplinary consensus has emphasised the need for institutional implementation strategies that recommend, where appropriate, more liberal clear liquid protocols to minimise prolonged fasting. Meaningful improvement therefore requires active implementation through routine measurement and audit of actual fasting durations relative to society recommendations, institutional accountability, and quality improvement initiatives that bridge the evidence–practice gap. Failure to implement strategies that prevent known harm is not a passive omission but an active decision, and addressing prolonged fasting is fundamental to delivering patient-centred perioperative care, improving the patient experience, and enhancing quality of recovery. Reducing prolonged perioperative fasting is a patient safety priority, not simply a guideline recommendation.
Intensivists will increasingly find themselves playing two roles in the era of climate change: treating the impacts of an increase in ambient temperatures on human physiology and minimising their contributions to the carbon emissions that are causing the planet to warm at an alarming rate. New data published in the British Journal of Anaesthesia quantify the carbon savings resulting from the choice of a lower oxygen saturation target rather than liberal oxygen use. We explore how environmental data can be integrated into clinical decision-making, and highlight the importance of system-level work to reduce the carbon footprint of clinical care.
