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13. Balshem H, Helfand M, Schünemann HJ, et al. GRADE 22. Hopewell S, Loudon K, Clarke MJ, Oxman AD, Dickersin K.
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9. Rating up the quality of evidence. J Clin Epidemiol 2011; 5. Rating the quality of evidence - publication bias. J Clin
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British Journal of Anaesthesia, 123 (5): 559e564 (2019)

doi: 10.1016/j.bja.2019.08.004
Advance Access Publication Date: 19 September 2019
© 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

Anaesthesiology in China: present and future

Qianzi Yang1, Keliang Xie2 and Lize Xiong1,3,*
1
Department of Anaesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi’an,
China, 2Department of Anaesthesiology, Tianjin Institute of Anaesthesiology, General Hospital of Tianjin Medical
University, Tianjin, China and 3Department of Anaesthesiology and Translational Research Institute of Brain and Brain-
Like Intelligence, Shanghai Fourth People’s Hospital, Tongji University School of Medicine, Shanghai, China

*Corresponding author. E-mail: mzkxlz@126.com

It has been 40 years since China implemented a policy of re- six other ministries in China, issued an important document
form and openness in December 1978. Over the past four de- entitled ‘Opinions on Strengthening and Improving Anaes-
cades, remarkable achievements have been made in China’s thesia Services’ ([2018] No. 21), which shed light on the
economic, social, and academic development. The Chinese detailed development of anaesthesiology in China in the near
Society of Anaesthesiology (CSA) was founded in 1979. Since future.
then, anaesthesiology in China has made great progress in the
disciplines of construction, education, modernisation, and
socialisation. The quality and safety of anaesthesia in China
Current status
have been remarkably improved, the social demand for It was not until 1989 that the Chinese Ministry of Public Health
anaesthesia has been met to a great extent, the number of recognised anaesthesiology departments as important clinical
anaesthetic practitioners has been increased substantially, entities in hospitals.1 Significant modernisation of anaes-
and international communication has been expanded. On thesiology as a recognised patient care medical specialty in
August 8, 2018, the National Health Commission (NHC), with China has blossomed in only the past two decades (Fig. 1).
 560 - Editorials

Fig 1. History and development of anaesthesia in China. In ancient China, the first documented anaesthetic was Mafeisan, invented by Hua
Tuo, a famous surgeon in the Three Kingdoms Period (220e265 CE). Modern anaesthesia in China followed the steps of its Western
counterpart, and was boosted in the past decades. CSA, Chinese Society of Anaesthesiology.

Anaesthesiology departments in China were largely ignored (2007e2017) were 6.8/10 000 and 0.7/10 000 anaesthesia
by hospitals, resulting in a lack of human resources and sparse cases7; these values were comparable with those of highly
deployment in facilities, and the quantity and quality of developed countries [according to the Human Development
equipment to administer anaesthesia and monitor patients Index (HDI) set by the United Nations Development Pro-
were insufficient in many hospital settings.2,3 gramme], such as USA,8 Germany,9 and Brazil.10
China’s economy has grown rapidly since then, and public In China, general anaesthesia accounts for ~80% of anaes-
demand for healthcare has also increased rapidly. Based on thetic procedures in most hospitals. Both inhalation anaes-
annual statistics released by the NHC of China, the number of thesia and TIVA are often used. The commonly used
inpatient surgeries in China has doubled in the past 10 yr. In anaesthetics in China are not different from those in Western
2017, the number of surgical procedures performed in China countries. In most tertiary hospitals, tracheal intubation is
increased to 56 million, most of which required anaesthesia. In performed via direct laryngoscopy, and the laryngeal mask
2014, there were 27.66 million anaesthesia procedures inside airway is used for 40% of general anaesthesia procedures in
the operating room (OR) and 11.47 million outside the OR in the China.
whole country.4 Anaesthesia has made a great contribution to Acupuncture is an important part of traditional Chinese
national healthcare improvement in China. medicine (TCM), and acupuncture anaesthesia was devel-
In recent years, China has witnessed extensive improve- oped from acupuncture analgesia.11 The first case of opera-
ments in anaesthesia care. According to a survey from 167 tion under acupuncture anaesthesia was performed in 1958.
countries published in 2015,5 there were 550 134 anaes- Subsequently, acupuncture anaesthesia was reported in
thesiologists worldwide; China had at least 77 926 anaes- many other operations (such as cardiac surgery, surgery on
thesiologists in 20144 and more than 90 025 in 2018. the anterior cranial fossa, total laryngectomy, and Caesarean
Currently, China maintains the largest number of anaes- section) in the 1960s and 1970s. As the requirement of
thesiologists, and the CSA has become one of the largest anaesthesia has expanded from pain prevention to sedation,
anaesthesiology societies worldwide. Investments in tech- muscle relaxation, amnesia, etc., acupuncture alone cannot
nology, facilities, education, and training have been meet the demands for most modern surgeries. In recent
increasing for years. The safety of anaesthesia in China has years, the combination of acupuncture with anaesthetics
also markedly improved. From the 1990s to the 2000s, the has been used for surgical operations in many Chinese
global incidence of perioperative cardiac arrest ranged from hospitals. Studies suggest that perioperative acupuncture
6.59/10 000 anaesthesia cases in highly developed countries reduces not only consumption of anaesthetic or analgesic
to 20.68/10 000 in less-developed countries.6 The incidence resources but also the incidence of anaesthesia-related
rates of overall and anaesthesia-related cardiac arrests in a complications, preoperative anxiety, and postoperative
Chinese tertiary hospital over a recent 10-yr period nausea and vomiting; it also protects organs in the
 Editorials - 561

perioperative period.12 Based on these many benefits, peri- number of well-trained anaesthesiologists and optimise the
operative acupuncture has been called acupuncture-drug structure of anaesthesia technicians. By 2020, the overall
balanced anaesthesia.12 number of anaesthesiologists will increase to 90 000, with 0.65
anaesthesiologists per 10 000 population. By 2035, the total
number of anaesthesiologists will reach 160 000, with 1.0
Main challenges anaesthesiologists per 10 000 population. Since the imple-
mentation of the resident training programme in 2014, China
Demand for anaesthesiologists has identified and selected 382 resident training centres for
The greatest challenge Chinese anaesthesiology has anaesthesia residents, and the number of recruits has
encountered in the new era is the burnout of physicians.13 increased annually. At present, a total of 12 000 residents have
Physician burnout is a worldwide problem, especially for been trained (Fig. 2).
anaesthesiologists; in China, a burnout rate of 69% in resi- The No. 21 document also encourages anaesthesiology de-
dents and 73% in attending anaesthesiologists was reported partments to establish additional posts for nurses, technicians,
in 2018.14 Although there were already 77 926 anaesthesiol- and other auxiliary staff. Before the release of this document,
ogists in China in 2014, the density was just 5.7 per 100 000 whether nurses could perform clinical anaesthesia prompted a
population,4 which was much lower than the densities in great debate in China. As early as 1989, the Chinese Ministry of
high-income countries, such as France (14.8), USA (12.7), and Health prohibited the administration of anaesthesia by nurses,
UK (11.5). The global ratio of surgeons plus obstetricians to and few anaesthesiology departments utilised nurses to
anaesthesiologists was 2.9:1, but China had a much higher deliver anaesthesia.17 However, the dramatic increase in
ratio of 7.5:1 in 2014.4 In terms of age distribution, 49% of anaesthesiologist workloads associated with the rapidly
Chinese anaesthesiologists are younger than 35 yr, and the increasing number of surgical procedures increased the de-
majority (83%) are younger than 45 yr.15 Long working hours, mand for anaesthesia nurses. Large numbers of nurses are now
heavy workloads, and fast-paced work are major factors working in anaesthesiology departments in Chinese hospitals,
associated with burnout.16 In China, physicians are also but there is great variability in the educational and training
stressed by medical responsibilities, research required for backgrounds of these anaesthesia nurses. Developing proper
promotion, and serving as the main source of family income. standards and policies for nurses to practice anaesthesia in the
According to a recent survey, overall occupational satisfac- clinic is the first step in expanding the number of anaesthesia
tion was less than 30%, and 43% of responders were inclined nurses. Anaesthesia nurses mainly focus on assisting anaes-
to switch to other jobs if they could.13 thesiologists in clinical work, including monitoring and
In August 2018, the NHC of China issued a document enti- recordkeeping, but do not participate in anaesthesia manage-
tled ‘Opinions on Strengthening and Improving Anaesthesia ment. Currently accepted principles are that anaesthesia
Services’ (No. 21). The document proposes to increase the nurses: (1) do not have medical decision-making power; (2) do

Fig 2. Training pathway of licensed anaesthesia practitioners in China. Current educational requirement for aspiring anaesthesiologists
includes two parts: 5e11 yr of medical school education for degrees and 3e5 yr of clinical training for certificates (standardised residency
training followed by advanced sub-discipline training). Most medical students have the option to pursue postgraduate studies in anaes-
thesia after earning their bachelor’s degree. Meanwhile, a small group of top students are allowed to finish their PhD in 8 yr, including 5 yr
of general medical education and 3 yr of study in anaesthesia. As the job and title of doctors relate closely with the policy of individual
hospitals, the after-school certificates do not necessarily guarantee the resident or attending positions. Although postgraduate education
is not compulsory, a higher degree is more helpful for doctors who are planning to find a job in a higher-level hospital. *Some joint
programmes enable students to earn both their master’s degree and standardised residency training certificate after 3 yr of study.
 562 - Editorials

not have prescription rights for medical drugs; (3) do not hospitals in the poverty-stricken counties as support-receiving
perform anaesthesia or deep sedation alone; (4) do not perform units. The project requires the teaching units to offer contin-
procedures such as central venous catheterisation and uous medical training, academic communication, and disci-
tracheal intubation alone; and (5) are in direct contact with the pline construction guidance and other activities to the support-
patient during PACU or ICU monitoring under the direction of receiving units. A series of training courses sponsored by the
the attending anaesthesiologists. The work rights and clinical CSA for the directors of anaesthesiology departments in the
skills of anaesthesia nurses need to be further regulated in support-receiving units provides classes in discipline con-
China. In December 2017, the National Health and Family struction, management, clinical safety, etc.
Planning Commission of China issued ‘notifications about the Globally, the increasing use of visualisation techniques in
setting of outpatient clinics and nursing units in the depart- anaesthesia procedures provides a safer and easier platform
ment of anaesthesiology’ ([2017] 1191). for anaesthesiologists. In 2016, 68.2% of anaesthesiologists
performed peripheral nerve blocks as blind procedures based
on anatomical landmarks.21 Ultrasound-guided regional
Imbalances in anaesthesia improvement
anaesthesia was used by only 12.8% of the anaesthesiologists
China is a large country with a substantial population (1.395 surveyed.22 Another Chinese survey revealed that 13% of car-
billion in 2018). The economic and clinical conditions vary be- diovascular anaesthesiologists always used transoesophageal
tween regions, especially between the coastal areas and west- echocardiography (TOE) intraoperatively for cardiac surgery;
ern (economically underdeveloped) provinces. The 48% usually used, 37% rarely used, and 5% never used TOE.23
distributions of populations, financial investments, technology, There has been significant recent improvement in the use of
educational resources, etc., are uneven, resulting in an imbal- ultrasound in China, which is still improving. Many Chinese
ance in expertise in anaesthesia care across the country as well. hospitals have started intraoperative ultrasound practices and
The quality of anaesthesia equipment is significantly higher training, including TOE in cardiac surgery, fast ultrasound
in hospitals in more economically developed regions of China scanning in emergent surgery, and ultrasound-guided nerve
than economically underdeveloped regions. Most of the blocks and vascular punctures. The technology of video-
equipment for anaesthesia delivery and physiologic moni- laryngoscopy has also been widely adopted across the country.
toring in hospitals in the western region is manufactured in Based on the airway anatomy of Chinese individuals, two
China, with a large proportion having been in service for more Chinese anaesthesia professors invented the UE video-
than 10 yr. In contrast, hospitals in the economically developed laryngoscope. Since 2011, more than 6800 hospitals in China
eastern regions of China have a patient care equipment have introduced the UE videolaryngoscope, of which 70% are
advantage, as they are able to import a large quantity of mod- tertiary hospitals, and full coverage has been achieved in more
ern equipment from overseas. The equipment performance, than 980 hospitals. The UE videolaryngoscope has also been
user-friendliness, reliability, and safety are likely enhanced. A exported to more than 20 countries and regions.24
study published in 201218 revealed that in Chinese hospitals
with more than 500 beds, especially in those hospitals that
provide general anaesthesia, basic oxygenation, automated
The future: from anaesthesiology to
NIBP monitoring, and ECG monitoring are usually provided.
These services are recommended in the World Federation of
perioperative medicine
Societies of Anaesthesiologists (WFSA) standards for the safe Chinese anaesthesiology continues to experience break-
practice of anaesthesia, but these hospitals cannot assure throughs in its development. Global postoperative mortality at
comparably acceptable end-tidal CO2 (ETCO2) and body tem- 30 days is still as high as 0.56e4%24e29 and 4.2 million per
perature monitoring, whereas many hospitals with less than year30; consequently, the CSA proposed that anaesthesiology
500 beds cannot meet either of these recommendations. should be considered perioperative medicine 4 yr ago. Since
Regarding the millions of high-risk anaesthesia cases, a 2016, CSA annual meetings adopted the theme of ‘from
report released in 201419 showed that only 13.3% of Chinese anaesthesiology to perioperative medicine’, and called for
anaesthesiologists surveyed monitor cardiac output (CO) anaesthesiologists to pay more attention to long-term out-
during anaesthesiology procedures, which is significantly less comes of surgical patients. On March 30, 2017, a press con-
than the 35.4% threshold recommended by the ASA and the ference was held in Beijing to initiate the first ‘China
34.9% limit recommended by the European Society of Anaes- Anaesthesia Week’ event, with ‘from Anaesthesiology to
thesiology (ESA) members.20 Anaesthesiologists rely much Perioperative Medicine’ as the theme. Annual China Anaes-
more on traditional haemodynamic monitoring, such as thesia Week activities popularise the knowledge of anaes-
noninvasive arterial pressure, invasive arterial pressure, and thesiology and perioperative medicine and educate the public
central venous pressure, for high-risk surgeries in China.19 It on what anaesthesiology can do for surgical patients and
should be noted that the financial costs of purchasing new postoperative recovery. To date, more than 50 hospitals in
monitoring devices as well as education and training on how China have changed their name from Department of Anaes-
to use these devices are challenges to improving the overall thesiology to Department of Anaesthesiology and Periopera-
quality of anaesthesia in China. tive Medicine. A number of multicentre clinical trials and
At the 19th National Congress of the Communist Party, clinical studies have identified endpoints as postoperative
Chinese President Xi Jinping’s report clearly pointed out that outcomes, such as the incidence of postoperative complica-
notable progress has been made in our country with regard to tions and mortality, rather than anaesthesia-related out-
poverty. In December 2017, a project entitled Precision Medical comes. The CSA has also organised a series of discussions with
Poverty Alleviation Alliance, which was initiated by the CSA, young anaesthesiologists on how to become leaders in peri-
was launched. The project selects anaesthesiology departments operative medicine.31
from more than 200 tier-3 hospitals to serve as teaching units Enhanced recovery after surgery (ERAS) is an important
and 800 anaesthesiology departments from county-level part of perioperative medicine. The core role of ERAS is to
 Editorials - 563

reduce surgical stress and allow the quick recovery of patient Declaration of interest
physiological function to the greatest extent, extending
The authors declare that they have no conflicts of interest.
throughout perioperative patient care. In 2018, the Chinese
Society of Surgery and the CSA jointly published the
‘Consensus on ERAS and guidelines for pathway management
in China (2018)’.32 At the same time, each hospital was also Funding
encouraged to determine its own path for ERAS practices.
National Natural Science Foundation of China (Grant No.
To meet the demands of clinical medical services and
81842018).
establish the leading position in perioperative medicine,
anaesthesiology may also take the lead in multidisciplinary
teams (MDTs) for pain management. In addition to acute and
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