Anesthesia Trauma Guidelines: A Systematic Review of Global Accessibility and Quality

Abstract

This systematic review describes the available clinical practice guidelines (CPGs) for the anesthetic management of trauma and appraises the accessibility and quality of these resources. This review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search was conducted across 8 databases (MEDLINE, Embase, Web of Science, CABI Digital Library, Global Index Medicus, SciELO, Google Scholar, and National Institute for Health and Care Excellence) for guidelines from 2010 to 2023. Two independent reviewers assessed guideline eligibility and extracted data, which were audited by a third reviewer. Data regarding author demographics, accessibility, clinical topics, and quality were collected. The quality of guidelines was evaluated according to the National Guideline Clearinghouse Extent Adherence to Trustworthy Standards (NEATS) Instrument. A total of 2426 articles were identified, of which 165 met eligibility criteria and were included. Guidelines were developed by 122 professional societies and authors from 51 countries. By region, Europe contributed with the most authors (61%), while Africa had the fewest (4%). Most CPGs were developed by authors from high-income countries (HIC) and only 12% had a first or last author from low- and middle-income countries (LMIC). The United States was the country with the most guideline authors. While 70% were open access, the average cost for paid access was US$36.61. Among the 8 languages identified, English was the most common. The most common topics were blood and fluid management, shock, and airway management. The overall quality of included guidelines was considered moderately high, with an average NEATS score of 3.13 of 5. Quality scores were lowest for involvement of patient perspectives, plans for updating, and presence of a methodologist. On logistic regression analysis, the involvement of a methodological expert was the only predictor of having a high-quality NEATS score, with no association observed with open accessibility, English language, society endorsement, first author from a HIC, or a multidisciplinary group composition. Though many countries and societies have contributed to the development of anesthesia CPGs for trauma, there has been a disproportionate lack of representation from LMICs, where the burden of trauma mortality is highest. In this study, we identify barriers to accessibility and areas for improving future guideline quality. We recommend ongoing efforts to incorporate perspectives from diverse settings and to increase the availability of high-quality, open-access guidelines to improve worldwide health outcomes in trauma.

Trauma is a leading cause of mortality and morbidity worldwide, accounting for the deaths of 4.4 million people each year.¹ Nearly 90% of deaths due to trauma occur in low- and middle-income countries (LMIC).² These worldwide disparities contribute to decreased life expectancy and quality of life for the nearly 82% of the global population who reside in LMICs.³

Accessibility and implementation of evidence-based guidelines in global health systems is essential to improve patient management and prevent avoidable deaths. Despite the many systematic, economic, and environmental factors that result in challenges to health care delivery in LMICs, the lack of evidence-based data and training has consistently been identified as critical gaps by experts.⁴ Clinical practice guidelines (CPGs) are valuable tools in health systems and are defined by the Institute of Medicine (IOM) as statements that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.⁵ The increasing development of CPGs over the past 2 decades has assisted in the translation of research findings to practical clinical applications.⁶ Yet, despite the potentially significant implications of CPGs to improve the standards of trauma care globally, there is limited information regarding their use in anesthesia worldwide. Efforts to identify gaps and barriers to quality guidelines in all countries are a global priority.

Anesthesiologists provide essential care in the perioperative period, often in emergent and complicated surgical settings. Anesthesia providers are responsible for the resuscitation, stabilization, and ongoing care of trauma patients. However, 1 study found that 80 different countries currently do not have a sufficient number of anesthesiologists to provide safe, quality anesthesia.⁷ In addition to a lack of specialized personnel, the quality of care administered to this large global population can also be compromised due to limitations in resources and funding.⁸ The utilization of CPGs is indispensable to enhance the standards of care for trauma victims, especially in high-risk areas with limited training opportunities.

To the best of our knowledge, there are no studies to date that investigate the availability, accessibility, and quality of CPGs for anesthesia in trauma care globally. This systematic review aims to describe the existing available anesthesia trauma guidelines. With improved accessibility and adoption of high-quality CPGs, strategies can be developed to address global disparities in the delivery of anesthesia care for trauma.

METHODS

We performed a systematic review of CPGs related to trauma care in anesthesiology, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P).⁹ The study protocol was published before conducting the review and registered in the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42022374941).

Literature Search

A health sciences librarian (B.H.) conducted literature searches on October 24, 2022 with an updated search on November 13, 2023.¹⁰ The following databases were queried: Ovid MEDLINE ALL (1946 to November 10, 2023); Embase (Embase.com, 1974 to November 13, 2023); Web of Science; CABI Digital Library; Global Index Medicus (World Health Organization); SciELO (Scientific Electronic Library Online); Google Scholar (first 100 citations) retrieved via Harzing, A.W. (2007) Publish or Perish, available from https://harzing.com/resources/publish-or-perish. Searches were limited to 2010 to the present. No other limits were applied. The National Institute for Health and Care Excellence (NICE)¹¹ online database was also reviewed manually for all guidelines relevant to anesthesia and trauma. See Supplemental Digital Content 1, Supplemental Text 1, http://links.lww.com/AA/F180, for the search terms and full search strategy.

Selection Criteria

Publications were considered eligible and included according to adherence to the definition of a CPG by the IOM.⁵ Thus, in addition to CPGs, professional society recommendations and consensus statements were considered. Article types that were excluded include randomized controlled trials, cohort and observational studies, descriptive review articles, audits, and adherence studies. Only studies from 2010 to 2023 were included. This timeframe was selected to review guidelines developed in the 10 years before COVID and more recent to ensure timely evidence-based guidelines. There were no language restrictions; however, full texts not available in team members’ primary languages were translated via Google Translate for analysis. CPGs that address the anesthetic and perioperative management of trauma were included. Due to the breadth of the specialty of anesthesiology globally, articles related to critical care, emergency medicine, and combat or austere care were considered. Other clinical topics, such as acute injury, shock, cardiopulmonary resuscitation, acute respiratory failure, hemorrhage, and burns were considered as part of the anesthetic management in trauma care. Surgical (nonanesthesia) and nursing guidelines were excluded.

Data Selection

Retrieved records were deduplicated and organized using the citation management software Endnote version 21 (Clarivate). After deduplication citations were then uploaded to Covidence systematic review software (Veritas Health Innovation) for screening and data collection. The guidelines underwent review with title and abstract screening followed by full-text screening by 2 independent reviewers. Any disagreements that arose were resolved by further team discussion or a third reviewer. Data extraction was subsequently performed separately by 2 independent team members and then all articles were audited by a third reviewer to resolve any discrepancies. This was done to minimize the risk of bias and to ensure the quality of data.

Data Extraction

The following information was obtained from the selected articles: (i) title and journal, (ii) date of publication, (iii) society affiliations, (iv) region by society and authorship (authors’ country of origin), (v) accessibility (language, cost, access type, number of steps to article retrieval), (vi) clinical topic and patient population, and (vii) quality. The quality of each guideline was assessed according to the National Academy of Medicine’s National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards (NEATS) Instrument.¹² The NEATS instrument evaluates reviews based on adherence to 12 core quality metrics: the disclosure of the funding source and Conflicts of Interest, involvement of patient perspectives; systematic review methodology; rating of strength of evidence, assessment of benefits and harms, linkage to evidence, rating strength of recommendations, clear articulation of recommendations, external review, and plans for updating.¹³ Each article was scored based on the NEATS 5-point grading scale, which was then used to classify into low (NEATS score <2), moderate (NEATS score 2–4), or high (NEATS score >4) quality of the guideline.

Data Synthesis and Statistical Analysis

Qualitative data and descriptive statistics are presented as frequency tables to summarize key findings of article information, region, accessibility, clinical topic, and quality. Density maps were produced through Microsoft Excel to display the distribution of authors’ origin by region and World Bank country classification by income level. Quality metric scores were calculated and presented as means and standard deviation (SD). A multiple logistic regression model was performed to test for an association of different predictive factors with obtaining an NEATS score of 4 or greater, and a separate regression was performed to test for an association with country income classification and open-access publication. STATA (StataCorp. 2023) statistical software was used for data analysis. Findings are reported as odds ratios. A value of P < .05 was considered statistically significant.

RESULTS

A total of 2426 citations were retrieved for initial screening, of which 165 met eligibility criteria for inclusion and underwent screening and data extraction (Figure 1). A list of all included guidelines can be found in Supplemental Digital Content 2, Supplemental Table 2, http://links.lww.com/AA/F181. Of these articles, 81% were labeled as a CPG, with 10% being consensus statements and 9% society recommendations. There was an average of 12 articles published each year (SD 3.9) and 53% of the articles were published after 2016; no significant trends were noted in publication volume over time. Nearly 85% of articles (n = 140) were developed or endorsed by a total of 122 different professional medical societies or working groups. The most referenced society was the French Society of Anesthesia & Intensive Care Medicine (SFAR) in 11 different guidelines. There were 22 societies that are exclusively from the United States.

Figure 1.

PRISMA flow diagram of guideline selection process. PRISMA indicates Preferred Reporting Items for Systematic reviews and Meta-Analyses.

Regional Demographics

There were 51 total countries represented by at least 1 author (Figure 2A), while 29 countries accounted for all first and senior authorship. When classifying by region, there were 103 guidelines (62%) with authors from Europe, 63 guidelines (38%) from North America, 28 (17%) from Asia, 11 (6.7%) from Australia and the Pacific, 11 (6.7%) from South America, and 7 (4%) from Africa. There were 33 (20%) articles that exclusively involved authors or societies from the United States, though authors from the United States partnered in the development of a total of 60 (36%) guidelines. Twenty-nine guidelines (17%) were international collaborations consisting of authors from 3 or more countries. Countries with the highest numbers of first authors include the United States (n = 48, 29%), Germany (n = 25, 15%), the United Kingdom (n = 19, 12%), and France (n = 18, 11%); trends were similar with senior authorship.

Figure 2.

Heat maps of anesthesia trauma guideline authorship by country. A, heat map of number of guidelines by country of origin of all included authors, and B, World Bank Classification by income level of all included guideline authors’ country of origin. Grey represents no country represented by authorship in any included guidelines.

When classifying by World Bank income level, 88.82% of articles had first authors from HICs. Only 1 guideline had a first author from a low-income country (Ethiopia), and 17 (10%) had first authors from middle-income countries. After including all authors, 41 guidelines (25%) included at least 1 author from a middle-income country and only 3 (2%) included authors from low-income countries (Figure 2B).

Accessibility

While the majority (70%) of the guidelines were open access, 30% required payment, society member, or institutional access to retrieve the reference (Table 1). The proportion of HIC and LMIC first-authored guidelines that were open access were 71% and 67%, respectively. There was not a significant association between the first authors’ country income level and whether a guideline was open access (odds ratio 1.19, P = .74). The costs for purchasing closed-access articles ranged from US$12 to 58.65, with an average cost of $36.61 (SD $8.88). Only 2 guidelines from LMIC first authors could be purchased at an average cost of $49.30; 4 closed access articles from a Chinese military journal were not available to purchase.

Table 1.

Accessibility Classified by First Authors’ World Bank Country Classification by Income Level

Accessibility metric	HIC (n = 146)	LMIC (n = 19)	Total (n = 165)
Open access
Yes	104 (71%)	12 (63%)	116 (70%)
No	42 (29%)	7 (37%)	49 (30%)
Average cost for paid access (USD)	$36.14	$43.37	$36.61
Average number of “clicks” for retrieval
1 click	32 (22%)	5 (26%)	37 (22%)
2 clicks	68 (47%)	6 (32%)	74 (45%)
≥ 5 clicks	37 (25%)	5 (26%)	42 (25%)
Language
English only	110 (75%)	10 (52%)	120 (73%)
English + other	4 (3%)	3 (17%)	7 (4%)
German	24 (16%)	0	24 (15%)
Spanish	4 (3%)	2 (11%)	6 (4%)
French	7 (5%)	0	7 (4%)
Mandarin	0	4 (22%)	4 (2%)
Russian	0	2 (11%)	2 (1%)
Turkish	0	1 (6%)	1 (0.6%)
Polish	1 (<1%)	0	1 (0.6%)

Abbreviations: HIC, high-income country; LMIC, low- and middle-income country; USD, United States dollar.

English was the published language of most guidelines (77%). The next most common language was German (15%), followed by Spanish (4%), French (4%), Mandarin (2%), Russian (1%), Turkish (0.6%), and Polish (0.6%). Only 6 (articles were published online in multiple languages (3.5%). When reviewing the number of web pages or “clicks” to view the guideline from a standard online search engine (Google), we found that while most (67%) articles took 2 clicks or less to access the articles, 44 (25%) still required 5 or more clicks to retrieve the guideline (Table 1).

Guideline Topics

Most guidelines are centered on hemorrhage, shock, fluid and blood management, and airway management (Table 2). This was consistent across all author income levels. Many guidelines discuss multiple topics including hemorrhage and coagulopathy, shock or hemorrhage and airway management, shock or hemorrhage and cardiopulmonary resuscitation, cardiopulmonary resuscitation and airway management, or brain injury in association with hemorrhage, coagulopathy, airway management, and cardiopulmonary resuscitation. In terms of specific patient populations addressed, 145 (88%) targeted the adult population and 45 (27%) explicitly described guidelines for the pediatric population. Other patient populations and contexts that were represented include obstetrics (6%), military (6%), and geriatric populations (2%). Considerations for coronavirus disease-2019 (COVID-19) emerged as a new topic and were discussed in guidelines from 2020 (n = 1) and 2021 (n = 2).

Table 2.

Clinical Topics of Guidelines

Clinical topic	Frequency (%)
Hemorrhage/blood management	50 (30%)
Shock/fluid management	49 (30%)
Airway/respiratory management	49 (30%)
Coagulopathy/anticoagulation	43 (26%)
Cardiopulmonary resuscitation	32 (19%)
Brain/head injury	30 (18%)
Monitoring	24 (15%)
Sedation/anesthetic agents	29 (18%)
Pain management	26 (16%)
Austere care (prehospital, combat, marine, altitude)	21 (13%)
Temperature management	20 (12%)
Infection/antibiotics	15 (9%)
Spine injury	14 (8%)
Burn injury	10 (6%)
Transport	7 (4%)
Ultrasound	7 (4%)
System factors	5 (3%)
Vascular access	3 (2%)
COVID-19	3 (2%)
Antiarrhythmic therapy	1 (0.6%)
Chemical/biological injury	1 (0.6%)
Imaging	1 (0.6%)
Glucose management	1 (0.6%)

Abbreviation: COVID-19, coronavirus disease-2019.

Quality Metrics

All 165 guidelines were evaluated according to the NEATS quality metrics. The overall level of quality of anesthesia trauma guidelines was considered moderate, with an average NEATS score of 3.13 of 5. The metrics with the highest adherence were the specific articulation of recommendations and the disclosure of Conflicts of Interest (Table 3). The metrics with the lowest average NEAT scores were integrating patient and public perspectives (NEATS 1.28) and making plans for updating (NEATS 1.42). Only 18 guidelines (11%) provide any mention of integrating patient and public perspectives and only 20 (12%) discuss plans for updating. Most guidelines were developed as part of a multidisciplinary group (82%). However, only 28% explicitly mention partnering with a methodologist and 55% disclosed the presence or absence of funding sources. On analysis, only the involvement of a methodologist was predictive of a CPG obtaining a NEATS quality score ≥4 (odds ratio 7.04, P < .001). There was no significant association observed with articles that were open access, English language, endorsed by societies, had a first author from a HIC, or that were developed from a multidisciplinary group with achieving an NEATS score ≥4 (Table 4).

Table 3.

Quality of Guidelines Assessed Through NEATS Grading Criteria

NEATS quality metric	Frequency (%)
Disclosure of funding source
Yes	91 (55%)
No	76 (46%)
Presence of multidisciplinary group
Yes	136 (82%)
No	23 (14%)
Unknown	6 (4%)
Presence of methodologist
Yes	46 (28%)
No	119 (72%)
	*Score (SD)
Disclosure of conflicts of interest	4.04 (1.7)
Patient and public perspectives	1.28 (0.9)
Use of a systematic review	2.53 (1.8)
Grading the quality of evidence	3.41 (1.7)
Benefits and harms of recommendations	3.87 (1.4)
Evidence summary supporting recommendations	3.78 (1.3)
Rating the strength of recommendations	3.38 (1.8)
Specific articulation of recommendations	4.58 (0.8)
External multidisciplinary review	3.76 (1.5)
Plans for updating	1.42 (1.2)

Abbreviations: NEATS, National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards; SD, standard deviation.

^*Using a 5-point numeric grading scale.

Table 4.

Predictive Factors of Having a High NEATS Score (≥4 of 5)

Predictor	Odds ratio	Standard error	z	P> ∣z∣	95% confidence interval
Open access	1.36	0.80	0.53	.60	0.41	4.3
Language (English)	4.55	3.66	1.88	.060	0.94	22.02
Society endorsement	3.86	3.21	1.63	.104	0.76	19.73
First author from HIC	1.13	0.97	0.15	.88	0.21	6.06
Multidisciplinary group	1.66	1.04	0.81	.42	0.49	5.65
Methodologist	6.81	3.05	4.29	<.001	2.84	16.37

Abbreviations: HIC, high-income country; NEATS, National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards.

DISCUSSION

This systematic review describes the current CPGs related to anesthesia care in trauma over the past 13 years. These guidelines have been developed by authors from 51 different countries and various professional societies worldwide. Though many countries and societies have contributed to the development of anesthesia CPGs for trauma, there is a lack of representation from LMICs, where the burden of trauma mortality is highest.^14,15 The area with the lowest guideline production is Sub-Saharan Africa. These findings are consistent with other reports of CPGs.^16,17 The disparities in representation from LMICs may result in guidelines that are not well-suited to the needs and resources of these regions, leading to suboptimal care and outcomes for trauma patients. The successful implementation of guidelines depends on applicability to the clinical setting and available resources. Prior reviews of CPGs have reported consistently low performance in local adaptability and consideration for resources and capacity.^18-21

Equitable guideline development and research support should be prioritized to address global health disparities. This can be achieved through initiatives such as increased funding for research in LMICs, publication of guidelines from LMIC authors, partnerships between institutions in high-income and low-income countries, and advocacy for policy changes at the international level.^22,23 In our study, 17% of guidelines were produced through international partnerships of 3 or more countries. International collaborative networks have previously been recommended to expand research and guideline development.^24,25 These international collaborations foster knowledge sharing, resource pooling, prevent unnecessary effort duplication, promote the exchange of best practices, and facilitate the adaptation of guidelines to diverse settings. Thus, we recommend ongoing efforts to expand balanced international scholastic and financial partnerships between HICs and LMICs and to incorporate perspectives from diverse settings through collaboration with local stakeholders.²⁶ Journals can also expand available guidelines by publishing guidelines from international authors from LMICs. This will help to ensure that guidelines are contextually relevant and practical, and could increase the dissemination and availability of high-quality, open-access local guidelines to improve worldwide health outcomes in trauma.

In terms of accessibility, we identified multiple potential barriers to retrieving CPGs. Our findings indicate that many articles were not published open access, with associated costs for purchasing. The average cost for paid access was US$36.76, with the highest cost of $58.65. This expense or a requirement for membership for nearly a third of articles may preclude access to medical professionals in underserved hospital systems where institutional support or financial resources are limited. As an example, in Uganda, where the annual Gross Domestic Product (GDP) per capita is ~$3300 according to the International Monetary Fund, the cost of each article could be equivalent to nearly 1.8% of a typical annual household income.²⁷ Although the costs to publish were not evaluated, journals commonly require an article processing charge (APC) to publish open-access articles, which can prevent this publication type for authors with limited funding. Subsidized APCs for authors from LMICs may be a useful strategy to promote increased publication of open-access, high-impact resources. Expansion of the accessibility of these resources to providers at trauma centers and referral hospitals in underserved areas could be a cost-effective strategy to improve quality of care through education and the implementation of evidence-based practices and protocols.

Another potential barrier to accessing information is language. Of all included guidelines published in HICs, 75% were published in English only, with 50% of articles from LMICs similarly in English only. Although this may be an underrepresentation of all guideline languages due to our search term strategy, there has been a historic dominance of the English language in science, and has been reported to account for up to 98% of scientific publications.²⁸ According to the World Bank, there are more than 3 billion people living in lower middle-income countries, with no country listed having English as the primary language.²⁹ The lack of guidelines available in native languages and the technical challenges of using translation software may hinder the use of current guidelines with medical providers in non-English speaking nations. Thus, it may be beneficial to expand the translations of existing guidelines and develop guidelines in local languages. Additionally, we found that the navigation of webpages to arrive at articles could be another hurdle for medical professionals worldwide, with 25% of the articles requiring 5 or more “clicks” to obtain access. We suspect that with more webpages that are needed to navigate in a nonnative language, the more difficult it becomes to find the desired guideline. However, this barrier has not previously been studied and future investigation is warranted to determine its impact.

When evaluating the topics most discussed in the included guidelines, there appears to be good correlation with actual anesthesia practice. The most prevalent topics were management of hemorrhage and blood products, shock and fluids, and airway and ventilation. According to the American Society of Anesthesiologists (ASA), “Trauma anesthesiologists manage difficult airways due to blood, vomitus, or severe facial fractures. They also provide massive blood and fluid resuscitation, treat coagulopathies, obtain vascular access, prevent hypothermia, optimize mechanical ventilation, and ensure adequate anesthesia and analgesia.”³⁰ These topics would be considered the primary role of any anesthesiologist, both in trauma management and most other surgical procedures. Patients suffering from trauma of all types often present for surgery with minimal prior history and with severe physiological derangements, making them among the most challenging patients to manage. In this invaluable role, anesthesiologists increase survival and improve outcomes, reducing morbidity and mortality.³¹ Therefore, the review of high-yield clinical topics and implementation of appropriate recommendations enabled by CPGs are an important aspect of delivering high-quality care to patients in acute and critical conditions. Most guidelines target the adult patient population, though roughly a quarter of publications also provide specific recommendations for pediatric patients. There was limited guidance for other specific patient populations, such as obstetric patients, geriatrics, or combat. Future guidelines should consider expanding recommendations to address diverse patient populations, which could be especially useful for practitioners in areas where there is limited subspecialty training.

CPGs should be reliable, high-quality resources to inform of the highest standards of care and clinical decision-making based on the available scientific evidence. This requires development through a rigorous methodological process to ensure recommendations that are clinically validated and free of bias. Different standards have been developed to evaluate the quality of these guidelines, including the National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards (NEATS) criteria and Appraisal of Guidelines for Research and Evaluation (AGREE II).^12,32 We utilized the NEATS instrument due to its succinct checklist and inherit scoring system to assess key components of guideline quality. This instrument has been utilized and validated in prior studies.¹³ Unfortunately, the quality of published CPGs has been scrutinized and efforts to appraise guideline quality have been performed across various disciplines.^33-37 In the field of Anesthesiology, a prior study appraising the quality of CPGs found improved quality scores over time, but reported that only 13.7% of guidelines met criteria for high-quality.³⁸

In this review, the overall quality of included guidelines was considered moderately high based on NEATS scores, though there was significant variability among references. The domains with the highest quality were the clear articulation of recommendations, disclosure of conflicts of interested, and multidisciplinary collaboration. However, metrics with the lowest quality scores that were identified among all studies were the lack of a methodologist consultant, lack of patient perspectives and representation, and lack of plans to update. These deficiencies have also been observed in other guideline review studies.^18,35 The inclusion of a methodologist significantly increased the likelihood of obtaining high-quality scores and is likely due to their expertise and contributions to improve the methodology for systematic reviews and the synthesis of evidence, which are then used to guide recommendations. Although the appraisal of individual recommendations was outside of the scope of this study, we rated the overall guidelines’ quality of evidence and use of grading schemes to assess strength of recommendations. Based on the adherence to these NEATS quality metrics, we report moderate scores of 3.41 and 3.38 of 5, respectively. A previous study of North American and European perioperative guidelines for anesthesiologists appraised the quality of 2280 recommendations utilizing the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system or American College of Cardiology/American Heart Association (ACC/AHA) classification system and reported that over half of recommendations from 2010 to 2020 were supported by low-level evidence.³⁹ High-level evidence is essential to ensure quality recommendations to guide care. We advocate for the ongoing efforts to involve methodological experts and integrate high-level evidence to inform recommendations and enhance the quality of CPGs.

International and multi-institutional collaborations have been previously shown to correlate with higher quality scores.³⁸ In this study, there was no observed association with overall quality and primary authorship from an HIC or guidelines written in English. This could be due to the involvement of multinational collaborations and authors from HICs in most guidelines. Yet, other authors have expressed concern of lower quality guidelines published in LMICs.^16,40,41 The production of guidelines that aren’t developed through rigorous standards can be counterproductive and overwhelm medical professionals with excessive and often contradictory or low-quality aids.³⁶ Therefore, key aspects of quality, such as thorough review and analysis of evidence, applicability, multidisciplinary and multi-institutional collaboration, diverse perspectives, clarity, and editorial independence, should be prioritized to maintain the highest international standards in the development of future guidelines.³² Furthermore, due to the evolving evidence, and to maintain up-to-date guidelines, it is recommended that guidelines undergo updating every 3 years.⁴² Interestingly, other factors that had no observed association with a high-quality NEATS score included open accessibility, professional society endorsement, or a multidisciplinary group. A previous study of national medical guidelines similarly found that CPGs developed by medical societies scored significantly worse than guidelines developed by governmental or unofficial working groups.⁴³ The reasons for these findings are unclear, but may reinforce the importance of external review and broader expertise with specialists in methodology and review processes to enhance overall quality.

Future Directions

Future efforts should prioritize the development, research, dissemination, and implementation of guidelines from or in collaboration with partners from LMICs and other diverse settings to provide practical and context-specific recommendations for care.⁴⁴ Professional medical societies from countries not currently represented by our identified authorship are encouraged to identify high-impact topics for trauma care and sponsor the development of relevant guidelines within their countries. This systematic review also identifies the need to improve open accessibility and expand resources in various languages, as well as clinical topics that are lacking in current publications. Furthermore, there should be continued emphasis on quality, especially with improvement in key areas of low quality identified in this review, to ensure the highest standards of guidelines.

Limitations

There are limitations to this study to consider. First, this review likely did not include all existing guidelines related to the anesthetic management of trauma. Although we attempted a broad search strategy with multiple databases and no language restrictions, the search terms used were in English and could have missed references in different languages. Clinical guidelines from various countries may have been published locally but may not all be indexed to international databases. This would result in an underrepresentation of available guidelines from LMICs and non-English sources. Additionally, due to lack of standardization, CPGs may vary substantially and can be published in various nontraditional platforms, such as the gray literature, society websites, and hospital networks, making them difficult to search and include. Another limitation is the classification of origin of guidelines by authors’ affiliated country. Authorship is just 1 component of the development, and additional insight through society members or reviewers may have contributed to guidelines production and regional input. Although all publication-listed authors were included in our study, we were unable to obtain data from papers submitted by task forces without cited authors. Lastly, there is the inherit risk of human error with screening and data collection. However, we utilized multiple independent reviewers with third party validation to minimize the risk and ensure the validity of data.

CONCLUSIONS

Trauma is a significant global health issue with disproportionately poor outcomes worldwide. The universal implementation of evidence-based practices based on international standards can assist in enhancing patient care and reducing global inequities. This systematic review describes the current available CPGs related to anesthesia care in trauma. There was significant regional variation in authorship, with most guideline authors from high-income countries. The scarce representation from LMICs may limit the applicability of recommendations for different resource environments and prevent the implementation in high-risk health systems. Although most current guidelines are open access, cost and language may present barriers to accessing online resources. Common topics discussed in these guidelines were blood and fluid management, shock, and airway or respiratory management. Although there was an overall moderate level of quality of included guidelines, areas for improvement for future guideline development are the involvement of a methodologist, incorporation of diverse perspectives, and plans for updating. We recommend efforts to promote international collaboration and development of high-quality guidelines to improve the anesthetic management and reduce disparities in trauma care.

Supplementary Material

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