Evidence Based Resource in Anaesthesia and Analgesia,2nd edition. M. Tramer (ed.). BMJ Books: London, UK, 2003, 208 pp; indexed, illustrated ISBN: 0-7279-1786-2; Price £30.00
This conveniently sized book, published by the BMJ Group and edited by Tramer, is a useful current review of evidence based medicine (EBM) and its application to selected topics in perioperative medicine. The pages are conveniently divided into 14 easily read chapters, grouped into three sections and written by a diverse group of authors.
Part one covers the relevance and current position of EBM in clinical decision making for individual patients. The three chapters contain a refreshingly honest discussion highlighting its limitations and a concise explanation of the need for randomized controlled trials (RCTs) and systematic reviews in anaesthesia and analgesia. Illustrated by relevant examples, they show how only good reviews of well conducted trials are useful and how misleading advice often results from poor methodology.
Part two contains seven chapters on perioperative topics where recent evidence is reviewed and possible recommendations are made. The first three of these deal with pain and analgesia. McQuay provides a comprehensive comparison of oral and parenteral postoperative analgesics and formulates EBM practice guidelines for the management of postoperative pain. He considers the risks and benefits of epidurals over general anaesthesia and the evidence regarding pre-emptive analgesia, transcutaneous electrical nerve stimulation and psychological techniques.
Moiniche and Dahl provide a useful account of evidence based methodology and an excellent review of peripheral treatments for postoperative pain. They consider wound infiltration, intra-articular injection and peripheral nerve blocks with a variety of agents. Due to poor study methodology of the currently published trials, they are unable to reach firm conclusions. However, they do clearly demonstrate how systematic evaluation guides the focus for future research. Halpern and Leighton discuss the effects of various epidural drugs, doses and delivery techniques on the progress of labour and mode of delivery. They also consider the impact of epidural analgesia on backache following childbirth. The remaining four chapters cover intravenous fluids for resuscitation, propofol for anaesthesia and sedation, postoperative nausea and vomiting (PONV), and prevention of central catheter related complications. Choi explores the conflicting conclusions of systematic reviews on intravenous fluid therapy and admits there are indeed other factors involved in a physician's choice of fluid. He mentions two large, good quality RCTs currently being conducted which may help clarify this contentious area. Tramer discusses assessment of patients at risk for PONV, with indications for prophylaxis and combination therapy for established PONV. This is an extremely useful chapter with clear guidelines for clinical practice. I found the chapter by Walder and Tramer on the evidence for the benefits and harmful effects of propofol well written but less useful than the other chapters. The choice of anaesthetic or sedative agent is more likely to be dependent on practical and financial considerations than the evidence presented here, although some of the information is useful on a practical level. Cooper and Randolph's chapter describes techniques to reduce the incidence of arterial puncture, infection and thrombosis complicating central catheter insertion. They highlight the magnitude and potential severity of this problem but accept that changing clinician practice is a great challenge.
Part three deals with the dissemination and incorporation of this information into clinical practice and how it might be utilized to guide future research. Pederson provides a dry but necessary account of the origin, evolution, structure and mechanics of the Cochrane Collaboration. Phillips provides a fine account of the necessity for and methodology behind assessing the cost effectiveness of interventions, in parallel with evaluations of efficacy. He comments on standardized health economic evaluations and their role in the national uptake of useful and efficient treatments. Lee and Gin discuss the difficulties transferring evidence into clinical practice and strategies available to aid application in the management in individual patients. Holte and Kehlet discuss the effect of postoperative epidural analgesia on outcome. They highlight the current difficulty in drawing any meaningful conclusions from the meta-analyses and argue that future methodology must include tight control of both study protocol and multi-modal postoperative rehabilitation programmes.
In summary this book is well written and informative. It does help busy clinicians separate the ‘nuggets from the mountain of dross’ and displays how to apply the evidence to clinical practice. It also highlights the poor quality of the majority of research, which is often conducted to bolster curriculum vitae or aid the marketing of a new product. Perhaps journals need to be more selective in minimizing useless and misleading research that often ends up being published.