Evidence Based Medicine in Peri-operative Care Wimonrat Sriraj M.D. Department of Anesthesiology, Faculty of Medicine, Khon Kaen University Phuket17/07/2008

Outline What What When When Which Which Where Where How to How to Example Example Evidence-based medicine Phuket17/07/2008

What evidence-based medicine is ? “Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” Sackett, et al 2001 Sackett, et al 2001 Phuket17/07/2008

Peri-operative anesthesia care Preanesthetic evaluation Preanesthetic evaluation Preanesthetic preparation Preanesthetic preparation Anesthetic management Anesthetic management Choice of Anesthesia Monitoring during anesthesia Prevention & management of anesthetic-related complication complication Postanesthesia care Postanesthesia care Postoperative pain management Postoperative pain management Phuket17/07/2008

Best 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, Organization Source eg. Journal, Organization Critical appraisal Critical appraisal Internal validity : Appropriate methodology Internal validity : Appropriate methodology Minimal bias Minimal bias Result : Magnitude, Precision Result : Magnitude, Precision Clinical VS Statistical significance External validity : Generalizability, Applicability External validity : Generalizability, Applicability Phuket17/07/2008

American College of Physicians BMJ Publishing Group Pre-filtered Journal Phuket17/07/2008

Level of evidence for recommendation Phuket17/07/2008

Searching for systematic review PubMed, At PubMed, At restrict to : Meta-analysis [pt] restrict to : Meta-analysis [pt] Review [pt] Review [pt] Phuket17/07/2008

Searching for systematic review PubMed, At PubMed, At restrict to : Meta-analysis [pt] restrict to : Meta-analysis [pt] Review [pt] Review [pt] The Cochrane library, The Cochrane library, At Search by review group/ topic Search by review group/ topic - Anesthesia group - Pain, palliative and supportive care group - Others eg. Pregnancy and childbirth group Phuket17/07/2008

Choice of Anesthesia “Caesarean section” Efficacy, safety Efficacy, safety Maternal & Neonatal effect Feasibility, practicality Feasibility, practicality Patient preference Patient preference Phuket17/07/2008

RA VS GA for C/S Anaesthesia for Caesarean section and neonatal acid-base status: a meta-analysis. Anaesthesia 2005;60(7): Anaesthesia for Caesarean section and neonatal acid-base status: a meta-analysis. Anaesthesia 2005;60(7): Regional versus general anaesthesia for caesarean section. Cochrane Database Syst Rev Oct 18(4): CD Regional versus general anaesthesia for caesarean section. Cochrane Database Syst Rev Oct 18(4): CD Spinal versus epidural anaesthesia for caesarean section. Cochrane Database Syst Rev Oct 16(2): CD Spinal versus epidural anaesthesia for caesarean section. Cochrane Database Syst Rev Oct 16(2): CD Phuket17/07/2008

Choice of Anesthesia Phuket17/07/2008

Maternal effect 1 Phuket17/07/2008

Maternal effect 2 Phuket17/07/2008

Neonatal effect 1 Phuket17/07/2008

Neonatal effect 2 Phuket17/07/2008

Reynolds F, Seed PT. Anaesthesia for Caesarean section and neonatal acid-base status: a meta-analysis. Reynolds F, Seed PT. Anaesthesia for Caesarean section and neonatal acid-base status: a meta-analysis. Anaesthesia 2005; 60(7): More neonatal acidosis in Regional anesthesia More neonatal acidosis in Regional anesthesia Umbilical pH difference ( 95% CI , ) Umbilical pH difference ( 95% CI , ) Base deficit difference ( 95% CI 0.434, mEq/l) Base deficit difference ( 95% CI 0.434, mEq/l) Neonatal effect 3 Phuket17/07/2008

Patient value Phuket17/07/2008

Patient value Phuket17/07/2008

Authors’ conclusion In terms of major maternal & neonatal outcomes : Not enough evidence to show that either RA or GA is superior to each other In terms of major maternal & neonatal outcomes : Not enough evidence to show that either RA or GA is superior to each other In low to intermediate income countries, the least expensive method should be chosen In low to intermediate income countries, the least expensive method should be chosen Phuket17/07/2008

Evidence-based Practice (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 anesthesia Phuket17/07/2008

Spinal VS Epidural anesthesia for C/S Phuket17/07/2008 No difference in terms of No difference in terms of Failure rate, Need for intraoperative analgesia Failure rate, Need for intraoperative analgesia Need for conversion to GA, Maternal satisfaction Need for conversion to GA, Maternal satisfaction Need for neonatal intervention Need for neonatal intervention Spinal anesthesia Spinal anesthesia Reduce time from start anesth to start operation Reduce time from start anesth to start operation weighted mean difference 7.91 minute (95%CI – 11.59, -4.3) Increase need for treatment of hypotension Increase need for treatment of hypotension RR 1.23 (95%CI )

Rapid recovery Rapid recovery Less nausea & vomiting Less nausea & vomiting Good postoperative pain Good postoperative pain Ambulatory anesthesia Regional VS General anesthesia

Ambulatory anesthesia Anesthesia Analgesia 2005; 101(6):

Outcome of interest Induction time Induction time Incidence of nausea & vomiting Incidence of nausea & vomiting Postop pain : VAS, rescue analgesics Postop pain : VAS, rescue analgesics Ability to bypass PACU Ability to bypass PACU Time in PACU, Time until discharge Time in PACU, Time until discharge Patient satisfaction Patient satisfaction

Finding RA RA Need more induction time ~ 8.1 minute Need more induction time ~ 8.1 minute Less postop pain Less postop pain PONV : PNB less but not with CNB PONV : PNB less but not with CNB More ability to bypass PACU More ability to bypass PACU Time for ambulatory unit stay : not reduce Time for ambulatory unit stay : not reduce CNB associate with delay discharge time ~ 35 minute CNB associate with delay discharge time ~ 35 minute

Implication for practice RA : Advantage but need more time RA : Advantage but need more time Busy ambulatory unit : ??? GA : Techniques, anesthetic drugs, GA : Techniques, anesthetic drugs, Prevention of PONV, severe P/O pain Prevention of PONV, severe P/O pain Cost effective, Policy, Patient value

Decision making Efficacy & safety Efficacy & safety Evidence based medicine Evidence based medicine (Best) Evidence, Expertise, Patient value (Best) Evidence, Expertise, Patient value Clinical circumstance Clinical circumstance Policy Policy Etc. Etc.

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