Anesthesiology, September 13 edition

This retrospective analysis describes A-QUA, a nationwide Swiss anesthesia quality program. By the end of 2024, its case-based registry contained 2,045,026 cases from 54 centers, enabling standardized benchmarking, detection of recurrent data-quality problems, and analysis of regional and hospital variation in anesthesia practice and postoperative disposition.

Impact: The registry demonstrates how standardized, nationwide anesthesia data can support continuous quality improvement and perioperative research at a scale rarely available in anesthesiology. Its value lies in infrastructure and reproducibility rather than a single clinical association.

Clinical Implications: Anesthesia departments and health systems can use comparable routine data to identify preventable documentation or process errors, benchmark practice patterns, target quality-improvement interventions, and generate hypotheses for future prospective studies.

Future Directions: Future work should link anesthesia processes to risk-adjusted patient outcomes, expand participation from smaller institutions, develop automated error-detection tools, and evaluate whether registry-informed interventions improve safety and efficiency.

In this prospective observational study of 789 patients undergoing laparoscopic gastrointestinal cancer surgery, postoperative pulmonary complications occurred in 33.19% within 7 days. Upper abdominal surgery, smoking intensity, and higher plateau pressure were independent risk factors; restricted cubic spline analysis suggested the lowest risk at a plateau pressure of 12–14 cmH₂O and significantly increased risk at 16 cmH₂O or higher.

Impact: The study links a clinically measurable intraoperative variable to postoperative pulmonary morbidity and proposes a practical pressure range for risk reduction. Although observational, the dose-response analysis provides a testable target for interventional trials.

Clinical Implications: For selected patients undergoing laparoscopic gastrointestinal cancer surgery, clinicians may consider avoiding plateau pressures of 16 cmH₂O or higher and targeting approximately 12–14 cmH₂O when compatible with surgical exposure and adequate ventilation. Smoking risk and immediate postoperative oxygenation should also be incorporated into perioperative planning.

Future Directions: Randomized trials should test plateau-pressure targets of 12–14 cmH₂O versus usual care, while accounting for driving pressure, positive end-expiratory pressure, recruitment maneuvers, surgical position, and patient-specific respiratory mechanics.

This randomized trial compared BIS-guided with end-tidal anesthetic gas concentration-guided general anesthesia in 674 elective surgical patients. Awareness occurred in 0.58% of the BIS group and 0.90% of the ETAG group, and the study concluded that neither strategy demonstrated superiority for preventing intraoperative awareness.

Impact: The study provides clinically relevant negative randomized evidence against assuming that BIS universally outperforms anesthetic gas concentration guidance. It supports a risk-stratified approach and highlights the need for adequately powered trials in patients at particularly high risk of awareness.

Clinical Implications: Routine BIS monitoring should not automatically be considered superior to end-tidal anesthetic gas concentration guidance for all elective surgical patients. Clinicians should integrate anesthetic concentration, hemodynamics, clinical context, neuromuscular blockade, and individual awareness risk when selecting monitoring strategies.

Future Directions: Future studies should enroll patients at high risk of awareness, use standardized awareness ascertainment and follow-up for psychological sequelae, compare prespecified BIS targets with ETAG targets, and evaluate cost-effectiveness.