Evidence Based Medicine Evidence Based Medicine in in

Peri-operative CarePeri-operative Care

Wimonrat Sriraj M.D.Wimonrat Sriraj M.D.Department of Anesthesiology, Department of Anesthesiology,

Faculty of Medicine, Faculty of Medicine,

Khon Kaen UniversityKhon Kaen UniversityPhuket 17/07/2008

OutlineOutline

What What WhenWhen WhichWhich Where Where How toHow to ExampleExample

Evidence-based medicineEvidence-based medicine

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What evidence-based medicine is What evidence-based medicine is ??

““Evidence-based medicine is the Evidence-based medicine is the integration of integration of best research best research evidenceevidence with with clinical expertiseclinical expertise and and patient valuespatient values” ”

Sackett, et al 2001Sackett, et al 2001

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Peri-operative anesthesia Peri-operative anesthesia carecare

Preanesthetic evaluationPreanesthetic evaluation Preanesthetic preparationPreanesthetic preparation Anesthetic managementAnesthetic management

Choice of AnesthesiaChoice of AnesthesiaMonitoring during anesthesiaMonitoring during anesthesiaPrevention & management of anesthetic-Prevention & management of anesthetic-

related related

complicationcomplication Postanesthesia carePostanesthesia care Postoperative pain managementPostoperative pain management

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Best evidenceBest evidence

Research, Practice guideline Research, Practice guideline Type of research eg. Systematic review, RCT, etc.Type of research eg. Systematic review, RCT, etc.

Source eg. Journal, OrganizationSource eg. Journal, Organization

Critical appraisal Critical appraisal Internal validity : Appropriate methodologyInternal validity : Appropriate methodology

Minimal biasMinimal bias

Result : Magnitude, PrecisionResult : Magnitude, Precision

Clinical Clinical VSVS Statistical significance Statistical significance

External validity : Generalizability , ApplicabilityExternal validity : Generalizability , Applicability

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American College ofPhysicians

BMJPublishing Group

Pre-filtered Journal

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Level of evidence for recommendation

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Searching for systematic Searching for systematic reviewreview

PubMed, At PubMed, At www.pubmed.comwww.pubmed.com restrict to : Meta-analysis [pt]restrict to : Meta-analysis [pt]

Review [pt]Review [pt]

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Searching for systematic Searching for systematic reviewreview

PubMed, At www.PubMed.comPubMed, At www.PubMed.com restrict to : Meta-analysis [pt]restrict to : Meta-analysis [pt]

Review [pt]Review [pt]

The Cochrane library, The Cochrane library, At At www.thecochranelibrary.comwww.thecochranelibrary.com

Search by review group/ topicSearch by review group/ topic- - Anesthesia groupAnesthesia group- Pain, palliative and supportive care group- Pain, palliative and supportive care group- Others eg. Pregnancy and childbirth group- Others eg. Pregnancy and childbirth group

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Choice of AnesthesiaChoice of Anesthesia

““Caesarean section”Caesarean section”

Efficacy, safetyEfficacy, safetyMaternal & Neonatal effectMaternal & Neonatal effect

Feasibility, practicalityFeasibility, practicality Patient preference Patient preference

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RARAVS VS GA for C/SGA for C/S

Anaesthesia for Caesarean section and neo Anaesthesia for Caesarean section and neo - - natal acid base status: a meta analysis. An - - natal acid base status: a meta analysis. An

aesthesia aesthesia 2005;60(7):636-532005;60(7):636-53 . .

Regional versus general anaesthesia for ca Regional versus general anaesthesia for ca esarean section esarean section.. Cochrane Database Syst R Cochrane Database Syst R

evev. . 2006 2006 Oct Oct 18(4):18(4): CD CD 004350 004350

Spinal versus epidural anaesthesia for caes Spinal versus epidural anaesthesia for caes arean section arean section. . Cochrane Database Syst Re Cochrane Database Syst Re

vv. . 2004 2004 Oct Oct 16(2):16(2): CD CD 003765 003765

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Choice of AnesthesiaChoice of Anesthesia

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Maternal effect 1Maternal effect 1

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Maternal effect 2Maternal effect 2

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Neonatal effect 1Neonatal effect 1

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Neonatal effectNeonatal effect 22

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Reynolds F, Seed PT. Anaesthesia for Caesar Reynolds F, Seed PT. Anaesthesia for Caesar - ean section and neonatal acid base status: a - ean section and neonatal acid base status: a

- meta analysis.- meta analysis.AnaesthesiAnaesthesia a 2005; 60(7): 636-2005; 60(7): 636-

53.53.

More neonatal acidosis in Regional More neonatal acidosis in Regional anesthesiaanesthesia

Umbilical pH difference -0.015 ( 95% CI -0.029, -0.001)Umbilical pH difference -0.015 ( 95% CI -0.029, -0.001) Base deficit difference 1.109 ( 95% CI 0.434, 1.784 Base deficit difference 1.109 ( 95% CI 0.434, 1.784

mEq/l) mEq/l)

Neonatal effectNeonatal effect 33

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Patient valuePatient value

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Patient valuePatient value

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Authors’ conclusionAuthors’ conclusion

In terms of In terms of majormajor maternal & maternal & neonatal outcomes : Not enough neonatal outcomes : Not enough evidence to show that either RA or evidence to show that either RA or GA is superior to each otherGA is superior to each other

In low to intermediate income In low to intermediate income countries, the least expensive countries, the least expensive method should be chosenmethod should be chosen

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Evidence-based Practice Evidence-based Practice (EBP)(EBP)

ASK

ACQUIRE

APPRAISE

APPLY

ASSESS

Decision making

Professional experience

Clinical expertise

Clinical circumstance

Patient preferences

Costs

Organizational issues

Politics

etc.

Professional experience

Clinical expertise

Clinical circumstance

Patient preferences

Costs

Organizational issues

Politics

etc.

The right

question

Systematically search for

the best evidences

Critically appraised for

validity & applicability

Judiciously applied to

the appropriate

patients

Choice of regional Choice of regional anesthesiaanesthesia

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Spinal VS Epidural anesthesia for C/SSpinal VS Epidural anesthesia for C/S

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No difference in terms of No difference in terms of Failure rate, Need for intraoperative analgesiaFailure rate, Need for intraoperative analgesia Need for conversion to GA, Maternal satisfactionNeed for conversion to GA, Maternal satisfaction Need for neonatal interventionNeed for neonatal intervention

Spinal anesthesia Spinal anesthesia Reduce time from start anesth to start operationReduce time from start anesth to start operation

weighted mean difference 7.91 weighted mean difference 7.91 minuteminute

(95%CI – 11.59, -4.3)(95%CI – 11.59, -4.3) Increase need for treatment of hypotensionIncrease need for treatment of hypotension

RR 1.23 (95%CI 1.00-1.51)RR 1.23 (95%CI 1.00-1.51)

Rapid recoveryRapid recovery Less nausea & vomitingLess nausea & vomiting Good postoperative painGood postoperative pain

Ambulatory anesthesiaAmbulatory anesthesia

Regional Regional VSVS General anesthesia General anesthesia

Ambulatory anesthesiaAmbulatory anesthesia

Anesthesia Analgesia 2005; 101(6): 1634-42

Outcome of interestOutcome of interest

Induction timeInduction time Incidence of nausea & vomitingIncidence of nausea & vomiting Postop pain : VAS, rescue analgesicsPostop pain : VAS, rescue analgesics Ability to bypass PACUAbility to bypass PACU Time in PACU, Time until dischargeTime in PACU, Time until discharge Patient satisfactionPatient satisfaction

FindingFinding

RA RA Need more induction time ~ 8.1 minuteNeed more induction time ~ 8.1 minute Less postop painLess postop pain PONV : PNB less but not with CNBPONV : PNB less but not with CNB More ability to bypass PACU More ability to bypass PACU

Time for ambulatory unit stay : not Time for ambulatory unit stay : not reducereduce

CNB associate with delay discharge time ~ 35 CNB associate with delay discharge time ~ 35 minute minute

Implication for practiceImplication for practice

RA : Advantage but need more timeRA : Advantage but need more time

Busy ambulatory unit : ???Busy ambulatory unit : ???

GA : Techniques, anesthetic drugs, GA : Techniques, anesthetic drugs,

Prevention of PONV , severe P/O painPrevention of PONV , severe P/O pain

Cost effective, Policy, Patient Cost effective, Policy, Patient valuevalue

Decision makingDecision making

Efficacy & safety Efficacy & safety Evidence based medicineEvidence based medicine

(Best) Evidence , Expertise, Patient (Best) Evidence , Expertise, Patient valuevalue

Clinical circumstanceClinical circumstance PolicyPolicy Etc.Etc.

Thank YouThank You