Evidence-based resource in anaesthesia and analgesia

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Evidence-based resource in anaesthesia and analgesia

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书籍相关信息
edited by Martin R. Tramer
London : BMJ Books, 2003
版本2nd ed
下面是BJA对这本书的介绍
British Journal of Anaesthesia, 2004, Vol. 92, No. 3 457-458
Book Review
Evidence-based Resource in Anaesthesia and Analgesia, 2nd Edn.
S. R. W. Bricker
Chester, UK
Evidence-based Resource in Anaesthesia and Analgesia, 2nd Edn.
M. R. Tramèr (editor).
Published by BMJ Books, London.
Pp. 194; indexed. Price £30.00. ISBN 0-7279-1786-2.
Medical authors lack the freedom enjoyed by other writers to create evocative titles, but even within those constraints this one remains a real clunker: barely grammatical yet with more than a hint of self-importance. This impression is not dispelled by an introduction in which the self-regarding tone is perpetuated by the editor’s assertion that ‘...this is not a conventional textbook. And those who are looking for authoritative opinion, eminence-based doctrine, and cookbook medicine will definitely be disappointed’. Indeed. A somewhat less partisan outline of the book does then follow, before he reminds us that ‘Economic constraints are increasingly interacting with clinicians’ freedom to use their favourite interventions’. A simple substitution even of the word ‘preferred’ for ‘favourite’, reveals just how condescendingly that comment has been phrased. It was some relief, therefore, to escape from this faint evangelism into Neville Goodman’s astringent critique of Evidence-Based Medicine, and what he describes as its central fallacy, namely that large epidemiological studies, meta-analyses and mega-trials can never reliably be applied to the management of individual patients. His is the initial contribution in the first section of the book, which continues with a discussion first of the purported superiority of large randomized trials, and then of the value of systematic reviews. They do aim to persuade, but by acknowledging some of the potential drawbacks of these techniques both appear even-handed.
The second part of the book comprises seven systematic reviews on clinical subjects. These begin with a contribution on acute pain by Henry McQuay. It contains much of interest to the anaesthetist, but has aspects that must surely have displeased his editor. He comments, for example, that ‘ideally (regional) blocks should not be done on anaesthetised patients’. What is this if not ‘authoritative opinion’? McQuay also dismisses the potential problem of addiction following treatment for acute pain by citing a single reference that is almost 25 yr old. I remain quite partial to a bit of eminence-based doctrine, but I am not sure how well this sits within a chapter of this kind. (It is curious moreover that he should find it necessary to explain patient-controlled-analgesia: ‘The patient presses a button and receives a pre-set dose of opioid from a syringe driver...’.) The second review, of the peripheral treatment of postoperative pain, includes an acronym of which previously I was unaware, the OQAQ, or Overview Quality Assessment Questionnaire. This is a means of scoring the methodological quality of each systematic review. With a maximum score of 7, only reviews achieving 5 or more were included, and these are listed over 7 pages (out of 18). By the time that they had reached the discussion, however, the authors were drawing attention to the limitations of the OQAQ that they had used, and were suggesting the option of QUORUM (The Quality of Reporting of Meta-Analyses Statement). At this stage I was in sore need of Neville Goodman’s assistance, but in its absence I had no choice but to accept the balanced conclusions of this contribution at face value. Much the same applied to the useful reviews of epidural analgesia for labour and delivery, postoperative nausea and vomiting (PONV), and to the chapter on preventing central venous catheter related complications. The section on propofol for anaesthesia and sedation concludes that a technique based on propofol rather than volatile agents reduced PONV, that it has both pro-convulsive and anticonvulsant properties, and that its adverse effects include pain on injection and hypotension. Perhaps these widely known facts require the authority of systematic review to give them credibility, but I did not feel that this was a chapter likely to excite huge interest. Which leaves the systematic review of i.v. fluids for resuscitation by Peter Choi. The crystalloid–colloid controversy is well known, while the analysis of albumin administration in the critically ill, produced in 1998 by the Cochrane Injuries Group Albumin Reviewers, succeeded in giving much comfort to those who already distrusted techniques of meta-analysis. Choi provides a valiant defence, but has to concede nonetheless, that in respect of these areas under discussion, what is needed are ‘Large, adequately powered, well designed, multicentre randomised controlled trials’.
The third and final section of the book is devoted to ‘dissemination, implementation, health economy and research agenda’, which again could have been scripted more enticingly. An otherwise detailed and useful explanation of the Cochrane Collaboration (with the usual reverent capital letters) by Tom Pedersen ends rather unpromisingly with a mission statement. The chapter by Ceri Phillips argues that the concept of cost effectiveness in anaesthesia and analgesia should form part of the evidence base, although some non-health economists might find the chapter somewhat indigestible. A sample passage comments, for example, that ‘There is ongoing debate as to whether non-financial gains should be discounted and the current recommendation is that benefits are presented as discounted in the base-case analysis and with no discounting in the sensitivity analysis.’ The contribution nonetheless is timely. The advent, for example, of activated protein-C at a cost of around £5000 for a single dose means that clinicians will have to confront this important issue, although the quote from Chestnut that ‘...it is not enough to be a good doctor in contemporary anaesthesiology practice...rather we must understand economics and business...’ will be for many a position too far. The contribution entitled ‘from evidence to implementation’ by Anna Lee and Tony Gin presents, in the editor’s words, ‘models to facilitate the application of the aggregate results of quantitative systematic reviews to the individual patient level’. I could not have put it better myself. They are attempting to counteract the ‘central error’ of EBM. They comment, however, that more than half of all systematic reviews in the anaesthetic literature have major flaws, and so require critical appraisal before issues of transferability (of the average treatment effect) and clinical applicability can be addressed. In addition to some more general observations about the obstacles that prevent dissemination and application of evidence, they also describe an interesting means of quantifying the risk-benefit analysis of any particular intervention in an individual patient. In essence a ratio of the number needed to harm (NNH) to the number needed to treat (NNT) is incorporated into an assessment that includes data from meta-analysis, patient preference, and economic cost. This then determines whether the prospective treatment is above or below the threshold line for net benefit. As the authors aver, this is intended to supplement and not supplant clinical judgement, but given that an anaesthetic episode of average complexity may involve 8 or 10 separate interventions, I doubt the practicality of its application.
The final chapter in the book by Kathrine Holte and Henrik Kehlet discusses the question of future research aimed at answering the question whether epidural analgesia improves surgical outcome. Professor Kehlet’s perspective on this subject is well known, and his name appears in 13 out of the 28 references that are cited at the end of an accessible and authoritative account, which delineates with some precision the problems with the meta-analyses and trials that have sought thus far to answer the question. The authors argue that the heterogeneity of the studies has undermined irretrievably this attempt, and that the answer will only come from randomized trials, provided that both the analgesic regimen and the perioperative care management are standardized. They scarcely acknowledge, however, that controlling these multiple factors, which range from patient information and stress reduction to fluid balance, has always, and will always present a formidable challenge. Which explains presumably the recourse to meta-analysis in the first place, and leads me to wonder whether the strict criteria of evidence-based methodology will prevent this particular challenge from ever being met.
I was going to end this review by querying whether this book differed greatly from the titles in the ‘Recent Advances’ or ‘Anaesthesia Review’ series. I realize on reflection that it is subtly different, mainly because of its underlying philosophical premise. I certainly believe that anaesthetists should be exposed to this particular approach via access to departmental or library copies, although whether they would wish to spend £30 on an individual copy is perhaps another matter.

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